30 | MAY 2019

COSMETIC USE AND DRY EYE

According to market research, roughly 66% of women regularly use eye makeup,1 particularly eyeliner and mascara, which are applied within close proximity

to the meibomian glands and ocular surface. Other commonly used cosmet-ics include creams, concealers, and eye shadows that are applied directly onto the eyelids and can be absorbed into the delicate eyelid skin or flake into the eye and tear film. Furthermore, makeup removers are often used around the eye, where they can leach into the tear film. Many of these types of products are toxic to the human ocular surface and adnexal cells.2

Every eye care provider should be well versed in the beauty practices of his or her patients, as the suspected correlation between eye health and makeup use (see The Cycle of Dry Eye Disease) is on the rise. Remember, the laws that govern the cosmetic

industry are 81 years old, established in 1938 by the Food, Drug, and Cosmetic Act.3 It’s also important to note that the men’s beauty market has grown and is considered to be among the best performing segments of the personal care industry.4 Below is a brief rundown of the many ways that cosmetic use can contribute to dry eye and related conditions.

THREATS TO THE OCULAR SURFACE Application of cosmetics to the

eye can contribute to corneal nerve irritation, dendritic cell activation, hyperosmolarity of the tear film, mei-bomian gland dysfunction, and tear film instability, along with symptoms of dry eye.5 The eyelid margin is an area of great concern with regard to overall tear film stability and ocular health, yet current beauty trends rec-ommend that this is the perfect place to apply eyeliner.

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False eyelashes increase risk for dry eye disease, as they compromise the protective mechanisms of natural lashes.

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Eyeliner and eye shadow can mask or mimic blepharitis. Eyelashes covered in mascara can hide evidence of Demodex infestation. Eyeliner on the lid margin can mask meibomian gland dysfunction.

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Many pigments used in eye makeup are nondissolving, and hard particulates can become lodged under a contact lens and scratch an unprotected ocular surface.

AT A GLANCE

Beauty products are not as harmless as they seem. BY LESLIE E. O’DELL, OD, FAAO; AMY GALLANT SULLIVAN, BS; and LAURA M. PERIMAN, MD

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Most patients are unaware that the eyelid margins contain the meibomian gland terminal ductules, which are important oil gland openings for deliv-ering protective oils to the tear film. However, trending makeup application techniques such as waterlining or tight-lining often block meibomian gland ori-fices and introduce chemicals that may interfere with ocular health. Eyeliner applied on the inner portion of the lash line has been shown to migrate into the eye 15% to 30% of the time.6 Patient education is paramount in changing this ubiquitous and harmful beauty trend.

Other aspects of eye makeup, such as estrogenic active ingredients and toxic preservatives, can contribute to localized endocrine modulation and result in a phenotypic dysregulation of the meibo-mian glands and the epithelia that are necessary for producing quality tears.

Another omnipresent ocular surface threat is the recent obsession with long eyelashes. In reality, unnaturally long eyelashes pose a risk for dry eye disease. Normal eyelash length is one-third of the width of the eye opening, enabling optimized ocular surface protection from allergens, dust, debris,

and air flow.7 When the lashes are abnormally lengthened, this impor-tant protective mechanism is lost.

BLEPHARITISEye makeup can throw eye care

providers off during an examination. Eyeliner, mascara, and eye shadow can mask or mimic blepharitis. Eyelashes covered in mascara can mask evi-dence of Demodex infestation.8 Eyeliner on the lid margin can mask evidence of ocular rosacea (telangi-ectasias) and mask meibomian fluid abnormality or gland dysfunction.

Use of false eyelashes is yet another area of concern. The glue used to adhere the false lash to the existing lash has been associated with con-tact dermatitis, allergic reactions, and inflammation that can exacerbate blepharitis (Figure 1). Also, proper lid cleaning is often not performed by people with false lashes due to a fear of lash loss, leaving a breeding ground for bacteria, fungus, and even Demodex.

ALLERGY AND INFLAMMATIONEyelash adhesives are cyanoacrylate-

like adhesives that often contain meth-acrylates, volatile organic compounds, and the well-known preservative and ocular irritant formaldehyde.9 The chemical cocktails used in many ocular cosmetics add to the risk of allergy for our patients, often presenting as con-tact or atopic dermatitis. Additionally, these chemicals can leach into the ocu-lar surface during application, creating a chemical conjunctivitis or chemical keratitis (Figure 2). Even nail polish and acrylic fingernails can cause chronic

dermatitis in patients because many contain high levels of volatile organic compounds and formaldehyde.

Complications of skin and eye products can also be related to allergy or toxicity. Creams and cosmetics used in beauty routines are often applied around the eyes, and vita-min A, retinoids, and parabens pres-ent in these formulations can have negative effects. These ingredients have been shown to cause significant toxicity to human meibomian gland cells in culture,10 and this is suspected to contribute to meibomian gland dysfunction and atrophy, and there-fore potentially to dry eye disease.11

Eyelash tinting and dyeing has been associated with severe conjunctival reactions, swelling, watering, and acute inflammation secondary to chemical toxicities and allergic reactions to the chemicals and dyes used around the eyes.12,13 Additionally, hydroxycin-namates, a class of aromatic acids or phenylpropanoids, are phytochemical (plant-based) oils known to directly activate transient receptor potential channels on nerves and immune cells, which may result in upregulation of proinflammatory cytokines IL-1B, IL-4, and IL-16, and neurotransmitters involved in pain and itch signaling.14

ISSUES SPECIFIC TO CONTACT LENS WEARERS

Mascara can be mechanically and chemically irritating if it flakes into the tear film. For contact lens wearers, these flakes can become trapped under a lens, causing corneal erosion.15 Many pigments used in eye makeup are non-dissolving, and hard particulates can become lodged under a contact lens and scratch an unprotected ocular surface.

BUYER AND CLINICIAN BEWARE Our patients’ beauty practices can

wreak havoc on the ocular surface, and labels such as plant-based, natural, organic, vegan, and ophthalmologist-tested do not equate to ocular surface safety. Eye care practitioners need to be aware of the potential adverse

Figure 1. Marked allergic and chemical conjunctivitis (A) after improper application of eyelash extensions applied to superior line of Marx (B) one day prior, blocking meibomian glands. This patient had to have the false lashes removed immediately due to her severe ocular symptoms.

Figure 2. This patient presented with significant blepharitis and complaints of dry eye 2 weeks after application of eyelash extensions. The patient admitted to discontinuing eyelid hygiene to prevent damage to the extensions.

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effects associated with the use of eye cos-metics and antiaging products. Educate yourself about the latest trends, and dis-cuss beauty routines with your patients, regardless of their gender. For information on beauty blunders, chemicals to avoid, and beauty habits to recommend, visit dryeyediva.com. n

1. Frequency of makeup use among consumers in the United States as of May 2017, by age group. Statista. www.statista.com/statistics/713178/makeup-use-frequency-by-age/. Accessed April 23, 2019. 2. Chen X, Sullivan DA, Sullivan AG, et al. Toxicity of cosmetic preservatives on human ocular surface and adnexal cells. Exp Eye Res. 2018;170:188-197. 3. Federal Food, Drug, and Cosmetic Act (FD&C Act). US Food & Drug Administration. www.fda.gov/regulatoryinformation/lawsenforcedbyfda/federalfooddrugandcos-meticactfdcact/default.htm. Accessed April 8, 2019. 4. Men’s personal care market to reach $166 billion, globally, by 2022-Allied Market Research. PR Newswire. October 19, 2016. www.prnewswire.com/news-releases/mens-personal-care-market-to-reach-166-billion-globally-by-2022-allied-market-research-597595471.html. Accessed April 23, 2019.5. Wang MT, Craig JP. Investigating the effect of eye cosmetics on the tear film: current insights. Clin Optom (Auckl). 2018;3:10-40.6. Ng A, Evans K, North RV, Purslow C. Migration of cosmetic products into the tear film. Eye Contact Lens. 2015;41(5):304-309.7. Amador GJ, Mao W, DeMercurio P, et al. Eyelashes divert airflow to protect the eye. J R Soc Interface. 2015;12(105). pii: 20141294.8. Buckley, RJ. Time to wake up to make-up. Ophthalmic Physiol Opt. 2012;32(6):443-445.

9. O’Dell LE, Sullivan AG, Periman LM. Beauty does not have to hurt. Advanced Ocular Care. 2016;July/August:42-47.10. Epstein SP, Ahdoot M, Marcus E, Asbell PA. Comparative toxicity of preservatives on im-mortalized corneal and conjunctival epithelial cells. J Ocul Pharmacol Ther. 2009;25(2):113-119.11. Ding J, Kam WR, Dieckow J, Sullivan DA. The influence of 13-cis retinoic acid on human meibomian gland epithelial cells. Invest Ophthalmol Vis Sci. 2013;54(6):4341-4350.12. Hansson C, Thorneby-Andersson K. Allergic contact dermatitis from 2-chloro-p phenylene-diamine in a cream dye for eyelashes and eyebrows. Contact Dermatitis. 2001;45(4):235-236. 13. Kaiserman I. Severe allergic blepharoconjunctivitis induced by a dye for eyelashes and eyebrows. Ocul Immunol Inflamm. 2003;11(2):149-151.14. Gouin O, L’Herondell K, Lebonvallet N, et al. TRPV1 and TRPA1 in cutaneous neurogenic and chronic inflammation: pro-inflammatory response induced by their activation and their sensitization. Protein Cell. 2017;8(9):644-661. 15. Watanabe T, Uematsu M, Mohamed YH, Eguchi H, Imai S, Kitaoka T. Corneal erosion with pigments derived from a cosmetic contact lens: a case report. Eye Contact Lens. 2018;44(Suppl 1):S322-S325.

LESLIE E. O’DELL, OD, FAAOn Director, Dry Eye Center of PA, York, Pennsylvanian Co-Chief Medical Editor, Modern Optometryn leslieod@hotmail.com; Twitter: @HelpMyDryEyes;

Instagram: helpmydryeyesn Financial disclosure: Consultant (Allergan, Johnson &

Johnson Vision, Sun Pharma, Takeda, Sight Sciences); Ambassador (TFOS); Subcommittee Member (TFOS DEWS II); Cofounder (Dry Eye Diva)

LAURA M. PERIMAN, MDn Cornea Fellowship Trained and Ocular Surface Disease

Expert; Director of Dry Eye Services and Clinical Research, Evergreen Eye Center, Seattle, Washington

n lauramperimanmd@gmail.com; Twitter: @Dryeyemaster

n Financial disclosure: Consultant (Advanced Tear Diagnostics, Allergan, Eyedetec, Eyevance, Lumenis, Johnson & Johnson Vision, ScienceBased Health, Sight Sciences, Sun Pharma, TearLab, Takeda, Visant, Umay); Ambassador (TFOS); Cofounder (Dry Eye Diva)

AMY GALLANT SULLIVAN, BSn Executive Director, Co-Founder, and Board Member,

TFOS, Boston, Massachusettsn amy@tearfilm.org; Twitter: @Eyeppl,

@DryEyeDiva; Instagram: DryEyeDivan Financial disclosure: Founder (Dry Eye Diva)

32 | MAY 2019

Figure adapted from: 2007 Report of the International Dry Eye Workshop (DEWS). Ocul Surf. 2007;5(2):85. www.tearfilm.org/dewsreport/pdfs/TOS-0502-DEWS-noAds.pdf. *Stars indicate the potential influence of cosmetics.Abbreviations: CL, contact lens; MGD, meibomian gland disease; NSDE, non-Sjögren syndrome dry eye; SSDE, Sjögren syndrome dry eye; TF, tear film

Aging

Low Androgens

EnvironmentHigh Air SpeedLow Humidity

BlepharitisLid Flora

Lipases EsterasesDetergents

Deficient or Unstable TFLipid Layer

XerophthalmiaOcular AllergyPreservativesCL Wear?

MGDHigh Evaporation

LowLacrimal

Flow

CoreMechanisms

LacrimalGland

neurosecretoryblock

initial lacrimal stimulation

Systemic Drugs Inhibit Flow

Inflammatory Lacrimal Damage SSDE; NSDE; Lacrimal Obstruction

Refractive Surgery CL Wear Topical Anesthesia

Tear Film

Instability

IL-1+TNFa+MMPs

Activate Epithelial

MAPK+NFkB+

ReflexBlock

NeurogenicInflammation

IncreasedReflex Drive

NerveStimulationNerve

Injury

Goblet Cell, Glycocalyx Mucin

Loss Epithelial Damage-Apoptosis

Tear Hyperosmolarity

THE CYCLE OF DRY EYE DISEASE*