OSD in women: Beauty has a price

False lashes, permanent eye makeup, tatoos can cause dry eye. Maybe Keats was referring to natural beauty.

By Cynthia Matossian, MD, FACS; Kendall Donaldson, MD, MS; Alice Epitropoulos, MD; and Marguerite McDonald, MD

For thousands of years, women and men have decorated their eyes with lash embellishments, permanent lid tattoos, and more recently, have instilled contact lenses and undergone lid surgery.

But at what cost to the health of the ocular surface? As it turns out, a steep price. Ophthalmologists with female patients — especially those “of a certain age” — need to be aware of the threats these embellishments pose to the ocular surface.

Figure 1. Elizabeth Taylor as Cleopatra.

What follows is a list of beauty treatments, their composition and what damage they can cause to the ocular surface.

Unnatural eyelashes

Eyelash extensions. Their popularity is striking. Type ‘eyelash’ into Google and ‘extensions’ pops up immediately. They are available in nail and hair salons, day spas and other establishments offering aesthetic services. Eyelash extensions are applied to each existing lash on the person’s lids to create a fuller, thicker look. A bonding agent is used to affix the synthetic lash to the natural one.

The National Consumer Affairs Center of Japan has reported that the number of cases, along with concerning signs and symptoms stemming from this process, are on the rise. They include: allergic blepharitis, keratoconjunctivitis, chemical keratitis and conjunctival erosion. These ocular problems are mostly related to the various adhesive agents.¹ Formaldehyde in concentrations above the standard threshold level was detected in several of these bonding agents. These glues are often formaldehyde-based, and may also contain rubber latex or other products that may elicit an allergic reaction.¹

False lashes. These synthetic lashes are glued along the lash line to deliver a fuller, longer look. Similar to lash extensions, the bonding agents to keep the strip of synthetic lashes in place along the lid margin are also formaldehyde-based, which may result in ocular irritation and allergic reactions.¹

A new study from Georgia Tech suggests that wearing fake eyelashes might cause more dust and air to hit the ocular surface, exacerbating evaporative dry eye.² This research team at the George W. Woodruff School of Mechanical Engineering analyzed the eyelashes of 22 mammals and discovered that the length of each eyelash should be about one-third the width of the eye to effectively protect against dust and minimize tear evaporation. Their findings demonstrate that if the lashes were longer, they would start to funnel air and dust particles into the eye. Their conclusion was simple: As lashes increase in length, they create a cylinder that channels air and molecules toward the eye and increases tear evaporation, leading to a greater likelihood of dry eye. They also stated that an increase in foreign particles funneled towards the ocular surface may lead to ocular infections.² The entire concept of ‘falsies’ is to provide unnaturally long lashes, hence increasing the risk of dry eye and infection.

Consistent application of fake lashes has also resulted in lash loss. Known as traction alopecia, the traction on the lash by the glues and false lashes leads to lash drop out. Moreover, during the removal process of the fake lashes, some natural ones also get removed.¹

Eyelash embellishments. These tiny decorations are added to the lashes for enhanced “bling” attraction. Small jewels or beads are threaded on ultra-fine wire then glued to the eyelashes. There are extreme lash embellishments, classified as uber lash embellishments, which include long feathers and vividly colorful plastic adornments.³ These can exponentially increase the risk of ocular surface irritation, lead to traction alopecia, and/or loss of lashes during their removal.

The AAO warns that among the potential dangers associated with cosmetic eyelash extensions and the adhesives used to apply them are infections of the cornea and eyelid, permanent or temporary loss of eyelashes and eyelid swelling. The AAO’s recommendation is to seek only the services of a certified aesthetician and watch that the aesthetician uses good hand-washing techniques.³

Permanent eyeliner or eyelid tattooing. Aestheticians perform this beauty treatment in salons by applying pigment along the eyelid margin, creating a permanent line. Tear film instability and ocular surface abnormalities have been reported years after the procedure, which can exacerbate ocular surface disease. Consequences of eyelid tattooing can range from blepharitis and meibomianitis to severe corneal staining with total meibomian gland dropout on meibography and subsequent tear film instability.⁴ Tear break-up time (TBUT) has been shorter in patients who have undergone eyelid tattooing when compared to control groups.⁵ Corneal erosion and corneal staining were more common in patients with permanent eyeliner compared to matched control groups.⁵

Figures 2. Eyelash extensions

Eye whitening. This technique occurs with the injection of white tattoo ink subconjunctivally.⁶ Rather than the more standard conjunctival excision with the addition of metabolites for a whiter appearance practiced in some countries, this novel approach described by Campion involves the injection of white tattoo ink into the subconjunctival space. It is then spread by external pressure to achieve the desired look.⁶ According to the authors, a homogeneous white appearance was readily achieved by distributing the white ink under the bulbar conjunctiva. Mild tearing, photophobia and seepage of ink during the first five days postprocedure were reported. Long-term data on the presence of permanent subconjunctival tattoo ink on the ocular surface are not available to date.⁶ An alternative method of eye whitening is called “regional conjunctivectomy” with or without injection of mitomycin. A recent publication reported an 83% complication rate of which 55% were considered severe. Forty percent of patients who had this procedure were dissatisfied or very dissatisfied.⁷ Cosmetic eye whitening is not recommended by most ophthalmologists.

Contact lenses. These are more commonly worn by women than men. In most cases, contacts offer an alternative option to wearing spectacles. For those who are active, engage in outdoor activities, or play sports, contact lenses are more ‘freeing’ than wearing glasses. On the other hand, some patients choose to wear contact lenses for ‘beauty’ reasons alone. These reasons include changing eye color from brown to blue or to add a glimmer to their eye by selecting one of the newer contact lenses that promotes ‘natural shimmer, natural sparkle, or natural shine’ to one’s look. Cosmetic contact lenses are also available with wild colors or unusual pupil designs. These nonprescription costume contacts become popular around Halloween and often are worn by costume seekers without an official contact lens fit by a professional eye care provider. After reports surfaced with these lenses causing eye injuries and infections, the FDA classified all contact lenses as medical devices and in 2005, restricted their distribution to licensed eye-care professionals only, effectively banning sales of non-prescription contact lenses. Their sale at gas stations and convenience stores is illegal. The AAO issues annual warnings about them.

Even nondecorative soft contact lenses impact the ocular surface; they reduce the tear volume and alter the components of the tear film. Increased lipases, degraded lipids and lipocalins in the aqueous tear film can potentiate dry eye disease.⁸ Contact lens over-wear or improper cleaning can lead to serious vision-threatening corneal problems.⁹

Cosmetic lid surgery. This surgery, particularly blepharoplasty, is becoming more popular in patients over age 50. This procedure is much more desired and pursued by women compared to men in this age group for the correction of droopy skin of the upper eyelids and the puffy bags involving the lower eyelids. Dry eye syndrome, or keratitis sicca, is a common condition that can adversely affect some patients undergoing blepharoplasty due to increased exposure postoperatively. In fact, many surgeons avoid performing this procedure on patients with more advanced dry eye disease for fear of worsening their ocular surface condition.

Figure 3. Permanent eyeliner or eyelid tattooing.

In some patients, blepharoplasty may cause inflammation, chemosis, reduced ability to blink completely, or ocular surface exposure, all of which can contribute to dry eye symptoms. In fact, postoperative dry eye is the most common cause of transient vision changes after blepharoplasty.¹⁰ Patients with ocular surface disease should be informed that blepharoplasty surgery could exacerbate their symptoms for several days, weeks, or even long-term.¹¹

Evaluations for dry eye

A presurgical tear analysis and screening can help identify patients who are at increased risk for postoperative dry eye. This may include tear osmolarity assessment (TearLab); MMP-9 evaluation (Inflammadry, RPS, Inc.); meibography, automated tear meniscus height measurement, automated tear-film breakup time, automated grading of conjunctival redness (a.k.a. RScan), automated tear-film viscosity measurement, and automated tear-film thickness measurement (Keratograph 5M, OCULUS USA); Schirmer test; and fluorescein staining during slit-lamp examination. Patients at higher risk include women who:

• are peri- or postmenopausal

• are taking birth control pills

• have a history of thyroid disease

• have a history of contact lens intolerance.

Conservative skin excision has been recommended by some authors to prevent exacerbation of dry eye disease.^12-15

Those who wear contact lenses should be instructed to wear their spectacles for the first few weeks postoperatively. Usually as the postoperative edema and inflammation resolves over a period of several weeks, the tear film should return to its preoperative baseline.

Figure 4. Eyelash embellishments.

Conclusion

The quest for beauty has caused some women to draw more attention to their eyes than they bargained for. There is no doubt that beauty empowers and self-esteem brings joy. Cosmetic eye treatments that many women (and men) resort to such as lash embellishments, cosmetic contact lenses, permanent lid tattoos and cosmetic lid surgery are tempting and powerful options for rejuvenation. However, some of these products and procedures can lead to serious infections, tear film instability, keratitis and exacerbation of dry eye disease. Surgeons and patients alike must be cautious of the apparent simplicity of these options.

We need to inform and advise our patients pre-operatively that cosmetic procedures are truly “surgery” that may have lasting effects on the health of their ocular surface. There is a real temptation to pursue these cosmetic enhancements, and many of our patients have undergone multiple procedures that create an additional deleterious effect on the ocular surface. Post-operatively, we need to counsel and provide support for these challenging patients when they struggle with ocular surface issues, advising them to resist the temptation to pursue yet further procedures to enhance their beautification. This is a challenging problem, particularly for aging women, in a culture that places such a high value on youth and beauty.

Take the right precautions. Use common sense when it comes to beautifying eyes, keeping eyes healthy while still looking beautiful. Truly, a thing of beauty is a joy forever. OM

REFERENCES

About the Authors
	Cynthia Matossian, MD, FACS, is the founder of Matossian Eye Associates. Her e-mail is cmatossian@matossianeye.com.
	Kendall E. Donaldson, MD, MS, is associate professor at the Bascom Palmer Eye Institute; she specializes in cornea/external disease and cataract/refractive surgery. She is medical director of the Bascom Palmer Eye Institute in Plantation, Fla.
	Alice Epitropoulos, MD, is a co-founder of The Eye Center of Columbus (Ohio); she practices at the Cataract and Refractive Center of Ohio.
	Marguerite McDonald, MD, is a cornea-refractive surgeon, Ophthalmic Consultants of Long Island, Lynbrook, N.Y.; clinical professor, NYU Langone Medical Center, N.Y.; adjunct clinical professor, Tulane University, New Orleans. margueritemcdmd@aol.com.