DED surveys: reality v. perception

Physicians say they talk to patients about the dangers lurking in cosmetics; patients say otherwise.

By Laura M. Periman, MD

A colleague¹ and I wanted to quantitatively explore the public’s — and physicians’ — perceptions of whether cosmetics affect dry eye disease. So we produced two separate surveys. We asked questions like: Did physicians tell their patients to read labels on eye makeup-remover bottles and did they avoid products that had BAK? Did physicians know that hypoallergenic means nothing regarding keeping the eye safe? And face moisturizers — did consumers know the dangers of the retinols?

If there was a separation between consumer patterns and provider knowledge of everyday skin care, cleansers, cosmetics and healthy habits, how large was it?

Chasm-size, it turns out.

In the consumer survey, in which 169 people responded,¹ 11% (Fig. 1) said their eye care provider talked to them about cosmetics while in the provider survey, in which 150 eye care professional replied,² 83% reported that they discussed cosmetics and skin care with their patients.

Fig. 1: Has your eye doctor ever talked to you about cosmetics?¹

In the provider survey, the questions explored their current state of knowledge regarding how cosmetics, and some ingredients therein, can exasperate OSD. Questions also explored practice patterns in discussing cosmetics, skin care and facial cleansers with patients. Other questions explored the level of knowledge of common cosmetics preservatives, retinoic acid-induced meibomian gland toxicity, product label safety, eye makeup removers and cosmetics. Among the eye care practitioners, 62% said they believed the label “hypoallergenic” indicates a safer product and 57% responded that “ophthalmologist tested” indicates a safer product. (Fig. 2) These results suggest that there is a general lack of understanding of cosmetics labels.

Fig. 2: Which cosmetics labels indicate a safer product for your patient?²

Fig. 3: Patients: When choosing makeup do you read the ingredients?¹

It’s not that consumers aren’t trying to be careful about their purchases. One-third said they made purchase decisions based on the label “hypoallergenic”. (Fig. 4)

Fig. 4: Patients: When choosing makeup, do you look for “hypoallergenic” in the name?¹

As we discussed in When Beauty Doesn’t Blink the term “hypoallergenic” has no FDA-defined standards nor enforcement. While the FDA site states that cosmetics are supposed to be tested for safety, companies are not required to submit their safety data.³ Without oversight or accountability, it appears these terms are of little reassurance to eye care providers and patients.

An online search for the definition and criteria for the “Ophthalmologist tested” label reveals only laboratories that contract out these services. The testing criteria and protocols were not described on the websites that were reviewed. In a discussion with one such company to define the testing criteria, a representative who requested anonymity admitted that “ophthalmologist tested” involves slit lamp exams looking for “irritation” during an observation period called ‘safety in use’ (typically just days 0, 1, 14).

Eye care provider respondents correctly identified that BAK is present in spermicidal creams, makeup removers and prescription ophthalmics. The epithelial toxic, inflammation- and apoptosis-inducing preservatives are important to identify given the evidence that methylparabens (another key chemical in eyeliners and mascara) demonstrate significant toxicity similar to that of benzalkonium chloride (BAK) in human conjunctival and corneal cell cultures.⁴

Most — 60% of providers — identified the vitamin A metabolite that is helpful as an anti-aging ingredient but also is damaging to the human meibomian gland cell culture. Retinoic acid, retinol and retin-A can promote OSD. A risk factor for MGD is exposure to 13-cis retinoic acid (13-cis RA), a metabolite of vitamin A.⁵ Retinyl palmitate is converted to retinoic acid, which can directly damage human meibomian gland epithelial cells. Systemic administration of a vitamin A metabolite, 13-cis-retinoic acid (Accutane), can result in severe dry eye, sometimes permanently. Retinoic acid induces inflammation and atrophy of sebaceous glands such as the meibomian glands. Retinoic acid directly induces pro-inflammatory cytokines IL-1B and MMP in human meibomian gland cell culture.⁵ Retinoic acid is the only compound studied to date that overrides the meibomian glands’ innate ability to prevent inflammatory responses.⁶

As clinicians, we are uniquely positioned to provide excellent recommendations and advice to our patients regarding their personal care, skin care, facial cleansers, cosmetics and makeup removal products. It is an important perspective to explore with your patients. Enhancing our communications efforts may facilitate this effort. OM

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About the Author
	Laura M. Periman, MD, is a cornea and refractive surgery trained ophthalmologist in Seattle, Wash. Her interests in immunopatho-physiology started as a research and development associate at Immunex Corp. in the 1990s. She can be reached at lauramperimanmd@gmail.com.