JOURNAL READING

ILMU MATA
RSUD JEND. AHMAD YANI METRO
FAKULTAS KEDOKTERAN UNIVERSITAS MALAHAYATI

Increased incidence of chalazion associated with face mask wear during

the COVID-19 pandemic

Rona Z Silkiss, MD FACS, Michael K Paap, Shoaib Ugradar, MD

a Division of Oculofacial Plastic Surgery, California Pacific Medical Center, 711 Van Ness Avenue Suite
340, San Francisco, CA, 94102, USA
b University of California, San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA, 92093, USA c
Division of Oculoplastics, Stein Eye Institute, University of California, Los Angeles School of Medicine,
100 Stein Plaza Driveway, Los Angeles, CA, 90095, USA

Oleh :
A. Hafidz Muzakki Al Faruq 21360111
Ibnu Aji Setyawan 21360150

Penguji :
dr. Melsa Ester Letareni Situmeang, Sp. M

KEPANITRAAN KLINIK ILMU MATA

RUMAH SAKIT UMUM DAERAH JEND AHMAD YANI METRO
FAKULTAS KEDOKTERAN UNIVERSITAS MALAHAYATI
TAHUN 2023
 Peningkatan kejadian chalazion terkait dengan pemakaian masker wajah selama
pandemi COVID-19

Rona Z Silkiss, MD FACS, Michael K Paap, Shoaib Ugradar, MD

a Division of Oculofacial Plastic Surgery, California Pacific Medical Center, 711 Van Ness Avenue
Suite
340, San Francisco, CA, 94102, USA
b University of California, San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA, 92093, USA c
Division of Oculoplastics, Stein Eye Institute, University of California, Los Angeles School of Medicine,
100 Stein Plaza Driveway, Los Angeles, CA, 90095, USA

Abstrak

Tujuan untuk menentukan apakah kejadian chalazion meningkat secara signifikan di

San Francisco Bay Area dan Los Angeles County setelah pemakaian masker secara luas
sebagai tanggapan terhadap pandemi COVID-19.

Metode Ini adalah studi multisenter retrospektif dari dua institusi oftalmologi: praktik
Okuloplastik swasta di San Francisco dan divisi Okuloplastik dari Stein Eye Institute di
University of California, Los Angeles. Semua pasien yang terlihat selama periode waktu
yang diteliti dengan diagnosis chalazion atau hordeolum diidentifikasi melalui tinjauan
catatan medis elektronik dan dimasukkan dalam penelitian. Insiden ditentukan untuk
setiap bulan antara Januari dan Agustus 2020, dan dibandingkan dengan data dari tahun
sebelumnya melalui ANOVA untuk mengevaluasi perubahan setelah awal pandemi.

Hasil Di San Francisco, kejadian chalazion meningkat secara signifikan pada bulan Juni
hingga Agustus 2020 jika dibandingkan dengan interval yang sama pada tahun 2016,
2017, 2018, dan 2019. Di Los Angeles, peningkatan kejadian chalazion pada tahun 2020
juga signifikan secara statistik jika dibandingkan dengan data tahun 2018 dan 2019.

Kesimpulan Pentingnya: Pemakaian masker yang meluas tampaknya berhubungan

dengan peningkatan kejadian chalazion. Risiko ini dapat diminimalkan, sambil tetap
mempertahankan manfaat perlindungan dari pemakaian masker, dengan mengambil
tindakan proaktif yang dibahas untuk mengurangi kekeringan mata akibat masker dan
perubahan mikrobioma kelopak mata.
INTRODUCTION

Sejak penyakit coronavirus novel 2019 (COVID-19) dinyatakan sebagai

pandemi oleh Organisasi Kesehatan Dunia (WHO) pada Maret 2020, upaya
untuk meminimalkan penyebarannya telah mencakup langkah-langkah
pencegahan seperti jarak sosial, kebersihan tangan, dan pemakaian masker
wajah. 1,2Di Amerika Serikat, penggunaan penutup wajah berbahan kertas atau
kain meningkat drastis selama pandemi, didorong oleh rekomendasi yang
dikeluarkan oleh Centers for Disease Control and Prevention (CDC)
pada April 2020. 2
Meningkatnya penggunaan masker wajah telah dikaitkan dengan konsekuensi
yang tidak diinginkan pada populasi umum, termasuk peningkatan insiden
jerawat yang didorong oleh peningkatan suhu dan kelembapan lokal. 3Karena
memakai masker wajah non-respirator umumnya mengarahkan napas ke atas ke
area periorbital (Gambar 3), telah dihipotesiskan bahwa memakai masker
semacam itu juga dapat menciptakan lingkungan mikro yang cocok untuk
peradangan kelopak mata dan berkontribusi pada perkembangan chalazion.4

Tujuan dari penelitian ini adalah untuk menentukan apakah kejadian

chalazion meningkat setelah penerapan penutup wajah kertas atau kain secara
luas sebagai tanggapan terhadap pandemi COVID-19. Melalui analisis
retrospektif catatan medis dari dua praktik Okuloplastik yang berbeda secara
geografis di California, kami mengeksplorasi kejadian chalazion sebelum dan
sesudah rekomendasi CDC untuk penutup wajah, membandingkan tingkat
selama periode waktu ini dengan tahun-tahun sebelumnya untuk menentukan
apakah ada korelasi antara penggunaan masker yang meluas dan kejadian
chalazion.

BAHAN dan METODE

Dalam studi retrospektif ini, rekam medis dari dua praktik Okuloplastik
California: praktik swasta (Silkiss Eye Surgery, San Francisco, AS) dan pusat
akademik rujukan tersier (Stein Eye, University of California, Los Angeles, AS),
dipisahkan secara geografis oleh 400 mil ditinjau. Di praktek swasta, rekam
medis antara bulan Januari dan Agustus, untuk tahun 2016–2020, dibuat
dianalisis untuk kejadian chalazion (kode CPT dan ICD10 67800, 67801,
H00.1) per semua
 kunjungan pasien. Metode yang sama digunakan untuk menganalisis data dari
pusat akademik dari tahun 2018 hingga 2020, di mana kejadian chalazion
dihitung di antara semua kunjungan untuk gejala okular. Semua analisis statistik
dilakukan dengan SPSS versi 22.0 (SPSS, Inc., Chicago, Illinois, USA). Analisis
varians (ANOVA) digunakan untuk menentukan apakah perbedaan kejadian
chalazion pada titik waktu yang berbeda signifikan secara statistik.

Penelitian ini berpegang pada prinsip Deklarasi Helsinki sebagaimana

diubah pada tahun 2008 sebagai Undang-Undang Portabilitas dan Akuntabilitas
Asuransi Kesehatan (HIPAA) tahun 1996. Tidaklah tepat atau mungkin untuk
melibatkan pasien dalam desain, atau pelaksanaan, atau pelaporan, atau
penyebaran rencana penelitian kami.

HASIL

Di kedua institusi, kejadian chalazion meningkat secara signifikan 2020

dibandingkan tahun-tahun sebelumnya. Di praktik swasta San Francisco (SF),
sebagian ditutup karena tindakan penguncian lokal pada bulan April dan Mei,
antara Juni dan Agustus 2020, 202 dari 1338 pasien terlihat karena chalazion,
yang mencerminkan insiden 0,151. Sebagai perbandingan, selama interval waktu
yang sama pada tahun 2019, 124 dari 1631 (kejadian 0,076) pasien terlihat untuk
chalazion (Tabel 1 Dan Gambar 1).

Di pusat akademik Los Angeles (LA), yang tidak menjalani penutupan

mandat kuncian yang sama, insiden chalazion mulai meningkat tajam setelah
deklarasi pandemi (Gambar 2). Antara Maret dan Mei 2020, 939 pasien terlihat
karena chalazion, yang mencerminkan kejadian 0,044. Selama interval waktu
yang sama pada tahun 2019, insidennya adalah 0,027. Antara Juni dan Agustus
2020, 1165 pasien terlihat karena chalazion (insiden 0,031). Dalam interval ini,
angka dari 2019 serupa, dengan 1165 pasien chalazion terlihat dan kejadian
0,028 (Meja 2). Perbedaan kejadian chalazion antara Januari dan September
2018, 2019, dan 2020 menunjukkan peningkatan yang signifikan pada tahun
2020 (f-ratio =
5,27 dan p<0,01).
 Chalazia diamati dalam berbagai tingkat keparahan pada kelopak mata
atas dan bawah, di lokasi medial dan temporal, dalam beberapa kasus semuanya
pada pasien yang sama (Gambar 4). Penulis tidak secara anekdot mengamati
kecenderungan perkembangan chalazion di wilayah periorbital tertentu setelah
permulaan pandemi, dan lokasi anatomi tidak dimasukkan sebagai variabel
dalam analisis data kami. .

Gambar 1.Insiden Chalazion di San Francisco Private Practice dan Kasus Baru
COVID19 di San Francisco County.
Insiden kalazion di San Francisco per bulan antara 2016 dan 2020, dibarengi dengan
insiden kasus baru COVID-19 selama bulan yang diteliti. Catatan April dan Mei
dikecualikan karena penutupan praktik selama perintah tinggal di rumah yang
diamanatkan oleh negara.
Gambar 2.Insiden Chalazion di UCLA dan Kasus Baru COVID-19 di Los Angeles
County. Kejadian tahun 2020,e chalazion di Los Angeles per bulan antara 2018 dan
dilapis dengan kejadian kasus baru COVID-19 sepanjang tahun 2020.

Gambar 3.Foto yang mengilustrasikan perpindahan aliran udara ke atas pada subjek
yang memakai masker wajah, seperti yang ditunjukkan oleh pengabutan lensa kaca
mata. Perhatikan pola fogging yang relatif seragam menunjukkan distribusi nafas yang
cukup merata di seluruh wilayah periokular.
DISKUSI

Studi ini mengungkapkan peningkatan yang signifikan dalam kejadian

chalazion di dua pusat oftalmologi yang berbeda secara geografis di California.
Pusat-pusat dipisahkan oleh jarak 400 mil.

Meningkatnya kejadian chalazion mungkin terkait dengan penggunaan

masker wajah secara luas. Telah dilaporkan bahwa pemakaian masker dapat
mempercepat penguapan air mata dan memperparah gejala mata kering.5,6 Pada
gilirannya, mata kering telah dikaitkan dengan blepharitis dan perkembangan
chalazion.7 Selanjutnya, dehidrasi telah diusulkan sebagai mekanisme
pengerasan minyak meibom dan pembentukan chalazion pada petugas kesehatan
yang memakai kacamata tertutup.4 Perubahan pada flora kelopak mata normal
juga bisa menjadi faktor. Meskipun disebabkan oleh obstruksi kelenjar meibom
kelopak mata yang tidak menular, perkembangan chalazion telah dikaitkan
dengan beberapa isolat bakteri spesifik serta perubahan mikrobioma
usus.7,8
Staphylococcus aureus, misalnya, umumnya terkait dengan blepharitis7 dan
sering
menjadi komponen flora mulut manusia.9 Bakteri patogen dan flora normal
rongga mulut masuk ke dalam droplet kadaluarsa melalui aktivitas seperti
berbicara, bersin, dan batuk.10 Oleh karena itu, pemakaian masker dapat
menyediakan corong untuk meningkatkan paparan bakteri pada kelopak mata
(dan kacamata pengabutan), yang memicu peradangan. Terakhir, penggunaan
masker sering kali disertai dengan penyesuaian manual yang sering, sehingga
meningkatkan kemungkinan perpindahan bakteri dari tangan ke wajah.

Peningkatan kejadian chalazion yang diamati agak tidak sinkron antara

dua institusi yang diteliti, memuncak pada bulan Juni di San Francisco dan April
di Los Angeles. Meskipun penjelasan untuk perbedaan ini kemungkinan
multifaktorial, faktor yang signifikan mungkin adalah penutupan praktik swasta
pada bulan April dan Mei, yang berarti setiap peningkatan kejadian chalazion
pada populasi pasien SF tidak akan tercermin dalam rekam medis selama selang
waktu tersebut. Perbedaan penting lainnya antara kedua kumpulan data adalah
durasi keseluruhan peningkatan chalazion, dengan insiden SF tetap meningkat
setelah
puncak awalnya dan insiden LA kembali ke tingkat yang sebanding dengan
tahun- tahun sebelumnya mulai bulan Juni. Variasi geografis yang sesuai dengan
pemakaian masker mungkin terlibat dalam perbedaan ini, 11 Meskipun data
analog tidak tersedia untuk San Francisco, kepatuhan masker publik yang
dilaporkan sendiri di seluruh negara bagian adalah 64% dalam survei Juni 2020 12
dan mungkin tetap lebih tinggi di bagian lain California, termasuk Bay Area.

Selain itu, penurunan cepat insiden chalazion yang diamati di Los

Angeles mungkin disebabkan oleh “kelelahan akibat krisis” dan penurunan
penggunaan masker yang dihasilkan beberapa bulan setelah dimulainya
pandemi. Ancaman COVID-19 yang berkelanjutan telah menyebabkan pesan
yang terus-menerus dan berulang kepada publik untuk terlibat dalam langkah-
langkah perlindungan seperti jarak sosial dan pemakaian topeng, menciptakan
kelelahan mental dan akhirnya tidak peka terhadap pesan semacam itu meskipun
awalnya ada kecemasan.13 Penurunan LA dalam kejadian chalazion berkorelasi
dengan rendahnya kepatuhan publik yang terlihat dalam studi Juli. Fenomena
serupa mungkin ada dalam data SF, di mana kejadian chalazion menurun pada
bulan Juli dan Agustus meskipun masih meningkat dibandingkan tahun-tahun
sebelumnya. Di kedua lokasi, kejadian chalazion puncak berhubungan dengan
periode kejadian baru yang relatif rendah kasus COVID-19 (Gambar. 1 Dan 2).
Menurut data New York Times,14 San Francisco County mengalami penurunan
tingkat infeksi pada bulan Mei dan Juni setelah kenaikan awal, sesuai dengan
insiden chalazion puncak yang kami amati pada bulan Juni. Di Kabupaten Los
Angeles, 15 tingkat infeksi terendah pada bulan April dan terus meningkat
hingga Juli, dengan insiden COVID-19 yang rendah pada bulan April sesuai
dengan puncak insiden chalazion yang diamati di UCLA. Hubungan terbalik ini
mungkin menunjukkan bahwa tingkat infeksi yang rendah di setiap lokasi
berhubungan dengan peningkatan pemakaian masker; pada gilirannya,
peningkatan insiden chalazion secara simultan dapat lebih lanjut mendukung
hubungan potensial antara penggunaan masker dan perkembangan chalazion.
 Gambar 4.Foto pembentukan chalazion parah pada orang muda yang melibatkan
keempat kelopak mata. Tabel 2

Kesimpulan

Peningkatan kejadian chalazion dengan penggunaan masker tidak

melebihi manfaat perlindungan yang signifikan dari penggunaan penutup wajah
selama pandemi. Namun, penulis merekomendasikan mengambil tindakan
proaktif untuk mengurangi risiko pembentukan chalazion. Langkah-langkah ini
termasuk penggunaan obat kumur antiseptik yang mengandung hidrogen
peroksida, alkohol, atau povidone iodine. Ini telah terbukti mengurangi beban
bakteri (serta beban virus SARS CoV-2 itu sendiri)) dan dapat mengurangi
kemungkinan pola pernapasan terselubung yang mengubah flora normal kelopak
mata dan daerah periorbital.16,17 Etiologi chalazion adalah multifaktorial 7 dan
masker wajah mungkin hanya menjadi penyumbang peningkatan insiden.
Namun, modifikasi perilaku termasuk sering mencuci masker wajah kain dengan
air panas, praktik kebersihan tangan yang baik, menghindari menyentuh wajah,
menghindari penyesuaian masker yang berlebihan, dan penggunaan pita perekat
di atas masker
 pada pangkal hidung untuk meminimalkan arah ke atas. udara ke arah mata dapat
membantu. Penggunaan scrub kelopak mata larutan asam hipoklorit 1% (Ocusoft
atau Avenova) sebagai bagian dari kebersihan kelopak mata setiap hari dapat
bertindak sebagai pencegah blepharitis antivirus dan antibakteri. Kami percaya
penerapan rutin dari metode ini dapat memberikan strategi yang efektif untuk
meminimalkan risiko pembentukan chalazion sambil mempertahankan
kemanjuran dan pentingnya penggunaan masker pelindung diri.

Meskipun penelitian kami terbatas pada temuan dari dua institusi di satu
bagian Amerika Serikat, kejadian chalazion yang signifikan pada kedua populasi
memerlukan penelitian lebih lanjut. Karena kedua praktik tersebut menerima
semua pasien, terlepas dari asuransinya, angka ini diperkirakan akan dipengaruhi
secara minimal oleh bias demografis dan mencerminkan populasi California, di
mana kepatuhan penggunaan masker relatif tinggi dibandingkan dengan wilayah
lain di Amerika Serikat.12

Persetujuan Pasien

Persetujuan untuk menerbitkan Laporan Singkat ini tidak diperoleh.

Laporan ini tidak berisi informasi pribadi apa pun yang dapat mengarah pada
identifikasi pasien mana pun yang diteliti.

Pendanaan

Penelitian ini didukung oleh Pacific Vision Foundation, San Francisco,

California, Grant number: 000100.

Kepengarangan

Semua penulis membuktikan bahwa mereka memenuhi kriteria ICMJE

saat ini untuk kepenulisan. Peran kredit diuraikan di bawah ini.

- RZS: Konseptualisasi; kurasi data; analisis formal; penyelidikan;

metodologi; administrasi proyek; pengawasan; validasi; menulis – meninjau &
mengedit
 - MKP: Kurasi data; analisis formal; penyelidikan; metodologi;
administrasi proyek; visualisasi; tulisan – draf asli; menulis – meninjau dan
mengedit

- SU: Konseptualisasi; kurasi data; analisis formal; penyelidikan;

metodologi; perangkat lunak; validasi; menulis – meninjau dan mengedit

Deklarasi kepentingan bersaing

Para penulis tidak memiliki konflik kepentingan untuk diungkapkan.

Terima kasih

Penelitian ini didukung oleh Pacific Vision Foundation, San Francisco,

California, Grant number: 000100.
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 American Journal of Ophthalmology Case Reports 22 (2021) 101032

journal homepage: www.ajocasereports.com/

Rona Z Silkiss, MD FACS a,*, Michael K Paap b, Shoaib Ugradar, MD c

a
Division of Oculofacial Plastic Surgery, California Pacific Medical Center, 711 Van Ness Avenue Suite 340, San Francisco, CA, 94102, USA b University of California,
San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA, 92093, USA c Division of Oculoplastics, Stein Eye Institute, University of California, Los Angeles School of
Medicine, 100 Stein Plaza Driveway, Los Angeles, CA, 90095, USA

ARTICLEINFO ABSTRACT
Keywords: Purpose: To determine whether the incidence of chalazion increased significantly in the San Francisco Bay Area and Los
Chalazion Angeles
COVID-19 Face
County following the widespread adoption of face mask wear in response to the COVID-19
mask dry eye
pandemic.
Blepharitis
Eyelid microbiome
Methods: This is a retrospective multicenter study of two ophthalmology institutions: a private Oculoplastics practice in San
Francisco and the Oculoplastics division of the Stein Eye Institute at the University of California, Los Angeles. All patients
seen during the studied time periods with a diagnosis of chalazion or hordeolum were identified through review of
electronic medical records and included in the study. Incidence was determined for each month between January and
August 2020, and compared to data from prior years via ANOVA to evaluate for changes after the onset of the pandemic.
Results: In San Francisco, the incidence of chalazion rose significantly in June through August of 2020 when compared to
the same interval in 2016, 2017, 2018, and 2019. In Los Angeles, the rise in chalazion incidence in 2020 was also statistically
significant when compared to data from the years 2018 and 2019.
Conclusion: Importance: Widespread mask wear does appear to correspond to an increased incidence of chalazion. This risk
may be minimized, while still maintaining the protective benefits of mask wear, by taking the proactive measures discussed
to decrease mask induced eye dryness and changes in the eyelid microbiome.

1. Introduction The aim of this study was to determine whether the incidence of
chalazion rose following the widespread implementation of paper or
Since the novel 2019 coronavirus disease (COVID-19) was declared a cloth face coverings in response to the COVID-19 pandemic. Through
pandemic by the World Health Organization (WHO) in March 2020, efforts to retrospective analysis of medical records from two geographically
minimize its spread have included preventive measures such as social disparate Oculoplastic practices in California, we explored the incidence
distancing, hand hygiene and face mask wear.1,2 In the United States, the use of chalazion before and after the CDC’s recommendation for face
of facial coverings made from paper or cloth rose dramatically during the coverings, comparing rates during these time periods to those from prior
pandemic, driven by recommendations released by the Centers for Disease years to determine whether there is a correlation between widespread
Control and Prevention (CDC) in April 2020.2 The increased use of face masks mask wear and chalazion incidence.
has been linked to unintended consequences in the general population,
including an increased incidence of acne driven by localized increases in
temperature and humidity.3 Since wearing a non-respirator face mask
generally directs breath upwards to the periorbital area (Fig. 3), it has been
hypothesized that wearing such masks may also create a suitable micro-
environment for eyelid inflammation and contribute to the development of
chalazion.4
R.Z. Silkiss et American Journal of Ophthalmology Case Reports 22 (2021)
al. 101032

2. Materials and methods

In this retrospective study, the medical records from two California

Oculoplastic practices: a private practice (Silkiss Eye Surgery, San Francisco,
USA) and a tertiary referral academic center (Stein Eye, University of
California, Los Angeles, USA), separated geographically by 400 miles were
reviewed. In the private practice, medical records between the months of
January and August, for the years 2016–2020, were Table 1
The incidence of chalazion per month in San Francisco between 2016 and 2020. Note
April and May are excluded due to practice shutdown during state- mandated stay-at-
home

* Corresponding author. 711 Van Ness Avenue Suite 340, San Francisco, CA, 94102, USA.
E-mail addresses: drsilkiss@silkisseyesurgery.com (R.Z. Silkiss), mpaap@ucsd.edu (M.K. Paap), ugradsahi@aol.com (S. Ugradar).
https://doi.org/10.1016/j.ajoc.2021.101032

Received 20 November 2020; Received in revised form 14 January 2021; Accepted 29 January 2021
Available online 9 February 2021
2451-9936/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

orders.
Jan Feb Mar Jun Jul Aug

2016 0.0418 0.0746 0.0875 0.0653 0.0603 0.0417

2017 0.134 0.0459 0.0545 0.0505 0.0339 0.0824
2018 0.0791 0.0916 0.0948 0.0705 0.097 0.0769
2019 0.0512 0.0532 0.0669 0.0821 0.0752 0.0752
2020 0.112 0.0936 0.0912 0.173 0.131 0.131

analyzed for the incidence of chalazion (CPT and ICD10 codes 67800, 67801,
H00.1) per all patient visits. The same methods were used to analyze data
from the academic center from 2018 to 2020, where the incidence of
chalazion was calculated among all visits for ocular symptoms. All statistical
analyses were performed with SPSS version 22.0 (SPSS, Inc., Chicago, Illinois,
USA). Analysis of variance (ANOVA) was used to determine whether the
differences in chalazion incidence at different time points were statistically
significant.
The research adhered to the tenets of the Declaration of Helsinki as
amended in 2008 as the Health Insurance Portability and Accountability Act
(HIPAA) of 1996. It was not appropriate or possible to involve patients in the
design, or conduct, or reporting, or dissemination plans of our research.

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3. Results

At both institutions, the incidence of chalazion rose significantly in

Fig. 1. Chalazion Incidence at San Francisco Private Practice and New Cases of COVID-19 in San Francisco County.
The incidence of chalazion in San Francisco per month between 2016 and 2020, overlaid by incidence of new cases of COVID-19 throughout studied months. Note April and May
are excluded due to practice shutdown during state-mandated stay-at-home orders.
R.Z. Silkiss et American Journal of Ophthalmology Case Reports 22 (2021)
al. 101032

Fig. 2. Chalazion Incidence at UCLA and New Cases of COVID-19 in Los Angeles County. The incidence of chalazion in Los Angeles per month between 2018 and 2020, overlaid by
incidence of new cases of COVID-19 throughout 2020.
R.Z. Silkiss et
al.
Fig. 3. Photograph illustrating upwardly displaced air flow in a subject wearing a face
mask, as demonstrated by fogging of eye glasse lenses. Note the relatively uniform
fogging pattern suggests a reasonably equal distribution of breath throughout the
periocular region.
2020 as compared to prior years. In the San Francisco (SF) private practice,
partially closed due to local lockdown measures in April and May, between
June and August of 2020, 202 of 1338 patients were seen for chalazion,
reflecting an incidence of 0.151. For comparison, during the same time
interval in 2019, 124 of 1631 (incidence 0.076) patients were seen for
chalazion (Table 1 and Fig. 1).
At the Los Angeles (LA) academic center, which did not undergo the same
lockdown mandated closures, chalazion incidence began to rise steeply after
the pandemic declaration (Fig. 2). Between March and May of 2020, 939
patients were seen for chalazion, reflecting an incidence of 0.044. During the
same time interval in 2019, the incidence was 0.027. Between June and
August
2020, 1165 patients were seen for chalazion (incidence 0.031). In this
interval,
numbers from 2019 were similar, with 1165 chalazion patients seen and an
incidence of 0.028 (Table 2). The difference in incidence of chalazion between
January and September 2018, 2019, and 2020, revealed that the increase in
2020 was significant (f-ratio = 5.27 and p < 0.01).
Chalazia were observed in varying severity on both the upper and lower
eyelids, in both medial and temporal locations, in some cases all in the same
patient (Fig. 4). The authors did not anecdotally observe a predilection for
chalazion development in any specific periorbital region following the onset
of the pandemic, and anatomic location was not included as a variable in our
data analysis.
4. Discussion
This study revealed a significant increase in the incidence of chalazion in
two geographically disparate ophthalmology centers in California. The
centers were separated by a distance of 400 miles.
The increased incidence of chalazion may be associated with the
widespread adoption of facial mask wear. It has been reported that mask
wear
The incidence of chalazion per month in Los Angeles Academic Practice between 2018 and 2020.
can accelerate the evaporation of tears and exacerbate the symptoms of dry
eye.5,6 In turn, dry eyes have been linked to blepharitis and
American Journal of Ophthalmology Case Reports 22 (2021)
101032
the development of chalazion.7 Further, dehydration has been proposed as a
mechanism for meibomian oil hardening and chalazion formation in
healthcare workers wearing sealed goggles.4 Alterations to the normal eyelid
flora may also be a factor. Though caused by a noninfectious obstruction of
eyelid meibomian glands, chalazion development has been associated with
multiple specific bacterial isolates as well as changes to the gut
microbiome.7,8
Staphylococcus aureus, for example, is commonly associated with blepharitis7
and is a frequent component of human oral flora.9 Bacterial pathogens and
normal oral flora are incorporated into expired droplets through activities
such as talking, sneezing, and coughing.10 Therefore, mask wear may provide
a funnel for increased bacterial exposure to the eyelids (and fogging
eyeglasses), promoting inflammation. Finally, mask use is often accompanied
by frequent manual adjustment, increasing the chances of transferring
bacteria from the hand to the face.
The observed rise in chalazion incidence was somewhat asynchronous
between the two studied institutions, peaking in June in San Francisco and
April in Los Angeles. Though the explanation for this discrepancy is likely
multifactorial, a significant factor may be the private practice’s closure in
April and May, which meant any increase in chalazion incidence in the SF
patient population would not be reflected in the medical records during that
interval. Another notable difference between the two datasets was the
overall duration of chalazion increases, with the SF incidence remaining
elevated after its initial peak and the LA incidence returning to rates
comparable to prior years starting in June. Geographic variation in
compliance with mask wear may be implicated in this difference, with an July
2020 observation study showing only 42% of people in a public section of
Los Angeles County wearing face
masks appropriately.11 Though analogous data is unavailable for San Francisco,
statewide self-reported public mask compliance was 64% in a June 2020
12
survey and may have remained higher in other parts of California, including
the Bay Area.
Additionally, the rapid decline in chalazion incidence observed in Los
Angeles may be attributable to “crisis fatigue” and resultant decreased mask
wear months after the onset of the pandemic. The ongoing threat of COVID-
19 has led to continued, repetitive messages to the public to engage in
protective measures such as social distancing and mask wearing, creating
mental fatigue and an eventual desensitization to such messaging despite
13
initial anxiety. The LA decrease in chalazion incidence correlates with the low
public compliance seen in the July study. A similar phenomenon may be
present in the SF data, in which chalazion incidence decreased in July and
August despite still being increased relative to prior years. In both locations,
peak chalazion incidence corresponded to a period of relatively low incidence
of new
Fig. 4. Photograph of severe chalazion formation in a young person involving all four
eyelids.
Table 2
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cases of COVID-19 (Figs. 1 and 2). According to New York Times chalazion incidence we observed in June. In Los Angeles County,15 infection
data,14 San Francisco County experienced a decline in infection rate rates were lowest in April and rose steadily until July, with the low
in May and June following an initial rise, corresponding to the peak COVID-19 incidence in April

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Jan Feb Mar Apr May Jun Jul Aug Sept

2018 0.0226 0.0222 0.026 0.0263 0.022 0.0257 0.0268 0.0243 0.0284
2019 0.0265 0.0241 0.0262 0.0251 0.0297 0.0305 0.0278 0.0262 0.0286
2020 0.0267 0.025 0.0347 0.065 0.0439 0.0322 0.0295 0.0311 0.0237

6
R.Z. Silkiss et
al.
corresponding to peak observed chalazion incidence at UCLA. This inverse
relationship may suggest that low infection rates in each location correspond
with increased mask wear; in turn, the simultaneous rise in chalazion
incidence may further support the potential association between mask wear
and chalazion development.
5. Conclusions
The increased incidence of chalazion with mask use does not outweigh
the significant protective benefits of wearing facial coverings during the
pandemic. However, the authors do recommend taking proactive measures
to mitigate the risk of chalazion formation. These measures include the use
of an antiseptic mouthwash containing hydrogen peroxide, alcohol, or
povidone iodine. This has been shown to reduce bacterial load (as well as the
viral load of SARS CoV-2 itself)) and may decrease the likelihood of masked
breathing patterns altering the normal flora of the eyelids and periorbital
region.16,17 The etiology of chalazion is multifactorial7 and face masks may
only be a contributor to an increased incidence. However, behavioral
modifications including frequent hot water washing of cloth face masks, good
hand hygiene practices, avoidance of face touching, avoidance of excessive
mask adjustment, and use of adhesive tape over one’s mask on the bridge of
the nose to minimize the upward direction of air towards the eyes may be
helpful. The use of a 1% hypochlorous acid solution eyelid scrub (Ocusoft or
Avenova) as part of daily eyelid hygiene may act as both an antiviral and
antibacterial blepharitis deterrent. We believe routine implementation of
these methods may provide an effective strategy for minimizing the risk of
chalazion formation while maintaining the efficacy and importance of
personal protective mask use.
Although our study was limited to the findings of two institutions in one
part of the United States, the significant incidence of chalazion in both
populations warrants further study. Since both practices accept all patients,
regardless of insurance, these rates are expected to be minimally influenced
by demographic bias and reflective of the population of California, where
mask adherence has been high relative to the rest of the United States.12
Patient consent
Consent to publish this Brief Report was not obtained. This report does
not contain any personal information that could lead to the identification of
any of the studied patients.
Funding
This research was supported by the Pacific Vision Foundation, San
Francisco, California, Grant number: 000100.
Authorship
All authors attest that they meet the current ICMJE criteria for
authorship. Credit roles are outlined below.
- RZS: Conceptualization; data curation; formal analysis; investigation;
methodology; project administration; supervision; validation; writing –
review & editing
- MKP: Data curation; formal analysis; investigation; methodology; project
administration; visualization; writing – original draft; writing – review
and editing
- SU: Conceptualization; data curation; formal analysis; investigation;
methodology; software; validation; writing – review and editing
Declaration of competing interest
The authors have no conflicts of interest to disclose.
American Journal of Ophthalmology Case Reports 22 (2021)
101032
Acknowledgements
This research was supported by the Pacific Vision Foundation, San
Francisco, California, Grant number: 000100.
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