Ever feel like you’ve tried everything for a patient with dry eye? You’ve explained the condition thoroughly. You’ve gone above and beyond to provide advice and strategies for daily lid hygiene. Yet your patient isn’t improving. Where do you go next?
Cosmetics can significantly impact the ocular surface. For dry eye patients, they can potentiate the cycle of disease and inflammation, as described by the Tear Film and Ocular Surface Society in the TFOS DEWS II Report.1 The prolonged use of cosmetics, especially when not effectively removed at the end of every day by the wearer, can result in a deficient or unstable lipid layer, epithelial damage, blepharitis, decreased aqueous production and even dynamic lid changes.1
When next performing a slit lamp exam, look for cosmetic complications on your patients’ lids, lashes and ocular surface
DEFICIENT OR UNSTABLE LIPID LAYER
Fragments of makeup often dislodge from the peri-ocular areas and, when they float in the tear film, they disrupt the normal lipid layer. They also lodge in meibomian gland orifices. This reduces meibum delivery to the ocular surface. A reduced ability for the tear film to spread causes increased frictional damage. The result? Tear film instability, hyperosmolarity and inflammation.
EPITHELIAL DAMAGE AND APOPTOSIS
Some cosmetic products have a six or twelve-month use-by date. Toxicity from preservatives used to prolong the shelf life of cosmetics can cause goblet cell damage and glycocalyx loss. This results in epithelial damage and apoptosis. On the slit lamp, you may recognise corneal staining and papillary conjunctivitis in cosmetic wearers.
Contamination is an important consideration due to bacteria and fungi. Each application of a cosmetic allows more pathogens to colonise the product and applicator. Bacterial overgrowth can occur near the lids, potentiating blepharitis. This leads to increased production of lipases and esterases. In the tear film, we see an increased detergent-like effect and lipid layer disruption. Demodex infestation may also occur.
DECREASED AQUEOUS PRODUCTION
Some cosmetics have a mild estrogen-like effect on the ocular surface. This leads to decreased aqueous production (non- Sjogren’s dry eye).
DYNAMIC LID CHANGES
Increased lash weight from wearing mascara or false eyelashes for example, changes the local airflow and evaporation pattern around the lashes. Skin tightening (e.g. Botox, Botox-in-a-jar) also affects the dynamic function of the lashes, which in turn affects the quality of a blink.
COSMETICS IN THE REAL WORLD
Recently, I borrowed my wife’s cosmetics. I searched up a list of ingredients for each (most websites required the visitor to tap ‘see more’ to expand the full ingredient list) and this is what I found:
Product 1: Skin Smoothing Cream
- Butylene glycol and pentylene glycol – known irritants,2
- Methylpropanediol – the website says “this substance causes serious eye irritation”,2 and
- Phenoxyethanol – this is a neurotoxic preservative that reduces the amount of paraben required (you will have seen products promoted as ‘paraben free’).3
Product 2: Serum
- Benzyl alcohol – this ingredient helps the cosmetic to dry on the skin. However, alcohol also dries out natural oils and moisture on the lids and ocular surface, which promotes an unstable tear layer.3
Product 3: Foundation
- Tetrasodium EDTA – there is some evidence of eye toxicity,2
- Phenoxyethanol, and
- Octyldodecanol – there is strong evidence that this is an irritant.2
Product 4: Liquid Foundation
- Alcohol and benzyl alcohol,
- Phenoxyethanol, and
- Cyclopentasiloxane – a bio-accumulative which is linked to uterine tumours in rats.2
Product 5: Eye Dust
- Methylparaben and polyparaben – these show similar cellular toxicity to benzalkonium chloride,4 and Polyethylene terephthalate – this has been described as “expected to be toxic or harmful”.2
OTHER COMMON COSMETIC INGREDIENTS
Other common ingredients you may encounter in cosmetics include:
- Argireline (acetyl hexapeptide-3) – an anti-aging product and a peptide that is a fragment of SNAP-25, a substrate of botulinum toxin. This ingredient is neurotoxic and reduces blink efficacy.3
- Benzalkonium chloride – this preservative is often in much higher concentrations than we normally see. It causes epithelial and goblet cell damage.3 If you do intense pulsed light therapy, check your makeup remover for benzalkonium chloride. You may be surprised to see it in the bottle.
- Formaldehyde (look for quaternium-15, DMDM hydantoin, or imidazolidinyl urea) – this preservative is toxic to the ocular surface.3
- Isopropyl cloprostenate – seen in eyelash growth serum, this is a synthetic prostaglandin analogue and is pro-inflammatory.3
- Retinol (found in anti-aging products) – Cis-retinol is particularly toxic to meibomian glands (including keratinization, apoptosis, interleukin 1 beta and matrix metalloproteinase inducing effects).5
- Sodium laureth sulfate – this strips the delicate oils of the eyelids and ocular surface and is often found in makeup removers.3
TIME TO OFFER PATIENTS RELIEF
When next performing a slit lamp exam, look for cosmetic complications on your patient’s lids, lashes and ocular surface. Ask your patients to send you a photo of their current products and check on their ingredients at Environmental Working Groups (EWG) (www.ewg.org/skindeep). By understanding more about the chemical make-up of cosmetics, it is possible to offer your patients relief from chronic inflammation and dry eye disease.
Leigh Plowman graduated with a Bachelor of Optometry (Therapeutic Endorsement) from the University of Melbourne in 2006. He practises at Otway Optical in Colac, Victoria. Mr Plowman is the founder of Dry Eye Directory as well as Optomly, a marketing consultancy for optometry.
- Tear Film and Ocular Surface Society. 2017 Report of the Dry Eye Workshop (DEWS Executive Summary). http:// www.tearfilm.org/dewsreport/index.html. Accessed May 21st 2020.
- Environmental Working Group- Skin Deep, www.ewg. org/skindeep. Accessed 21 May 2020
- O’Dell, LE. Sullivan, AG. Periman LM. ADVANCED OCULAR CARE | JULY/AUGUST 2016.
- Epstein SP, Ahdoot M, Marcus E, Asbell PA. Comparative toxicity of preservatives on immortalized corneal and conjunctival epithelial cells. J Ocul Pharmacol Ther. 2009;25(2):113-119.
- 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;54:4341-4350