As clinicians, we rarely discuss cosmetics and beauty topics with patients. In a recent survey, 85% of patients said their eye doctor never asked them about their cosmetics exposures or beauty practices.¹ Anyone concerned about ocular surface disease (OSD), however, should recognize that there are very real health costs associated with everyday beauty practices and products.

While women are the primary consumers of eye makeup and eyelash treatments, men are increasingly following suit. “Bro beauty” trends suggest that men are using more skin care and makeup products and paying far more attention than in the past to grooming facial hair, including eyelashes and eyebrows.

In this article, I’ll discuss the ocular surface risks associated with a range of eye-related beauty products and treatments, with a special focus on eyelash treatments.

EYE MAKEUP

Many of the adhesion, emulsification and preservative chemicals used in cosmetics are known ocular surface toxins. While the FDA regulates makeup and cosmetic products under the Federal Food, Drug and Cosmetics Act, it does so with a very light hand compared to other industrialized countries. The United States bans just 11 chemicals in cosmetics, for example, compared to the more than 1,300 banned by the European Union.

Consistently removing eye makeup before sleeping is associated with fewer dry eye symptoms and lower SPEED scores.¹ However, makeup removal itself carries hazards, as the liquid solutions commonly used for removing waterproof mascara and eyeliner often contain harsh chemicals, including benzalkonium chloride (BAK), a known disrupter of epithelial and goblet cells. Dry eye patients with excess tearing often migrate toward waterproof products, which inadvertently add significantly to their OSD, exacerbating chemical burden. Cosmetic manufacturers are only required to list ingredients that make up more than 1% of the total product volume. If BAK is in the ingredients list, it may be present in a much higher concentration than in any preserved ophthalmic drop.

PRESERVATIVES FUEL THE OSD FIRE

Parabens are another category of preservative commonly used in over the counter (OTC) skin care (both men’s and women’s products). Parabens are also prevalent in cosmetics (eg, butylparaben, methylparaben, propylparaben). Not only are these xenoestrogens believed to penetrate the skin and potentially disrupt hormone function, but they are nearly as toxic to human meibomian gland epithelial cell culture as BAK.²

THE RISKS OF “ALL NATURAL”

Many consumers mistakenly believe that cosmetics labeled as “hypoallergenic,” “all natural,” “organic,” or even “ophthalmologist tested” will be safe for their skin and eyes. In reality, these beauty labels mean very little. One “organic, vegan and dermatologist-tested” eyeliner product that I recently reviewed contained eight known ocular surface-offending chemicals. Moreover, “natural” does not automatically mean “good for the eyes.” Some “natural” plant-derived components and oils, such as cinnamates, may be pro-inflammatory and directly fuel dry eye disease immunopathophysiology. These ingredients activate TRPV1 and TRPA1 receptors on the immune system’s dendritic cells and the corneal nerves.³ These cell surface receptors are like a common language for both the immune and nervous systems.

It is also not unusual for high-end eye makeup products to be marketed as containing minerals, mica or even semi-precious gems, such as tourmaline in the case of the most expensive department store brands. Even though minerals are “natural” and sound healthful to laypeople, I doubt that ophthalmologists would recommend the use of crushed rock in and around the eyes. Magnified, these components appear to be small crystals or shards (as one might expect) that may actually become embedded in the subconjunctiva or lids (Figure 1).

PERMANENT MAKEUP

Dry eye patients with symptoms from cosmetics often turn to eyeliner tattoos — thought of as a way to make beauty effortless and “always on.” Unfortunately, eyeliner tattooing is associated with MGD.⁴ This association could be patient self-selection, chemical and mechanical damage or a combination of all of the above.

The inks used for the tattoos may contain titanium dioxide, lead, nickel and industrial grade paint pigments, as well as the preservatives previously discussed. Mechanical microtrauma from the tattoo gun may lead to acute blepharitis and keratitis (Figure 2) as well as subsequent meibomian gland dropout and even loss of the lid margin architecture.⁴

Many people also seek a semi-permanent chemical tinting (think hair dye) of the eyelashes, with or without a “lash lift.” The latter is a method of curling the eyelashes that is accomplished with a “perm” (yes, just like women used to get in the 1980s). Aside from the potential chemical toxins used in these home and salon eyelash “perm” treatments (such as highly alkaline ammonium thioglycolate), improper hygiene at salons and medi-spas where the procedures are performed may contribute to the spread of bacteria, fungus and even Demodex mites.

ANTI-AGING TREATMENTS

Like eye cosmetics, many lotions and skin-care products contain chemicals that can be harmful to the lid, cornea and conjunctival cells if they come in contact with the area surrounding the eyes. Even if applied well outside the orbital area, beauty products can migrate.

Botulinum toxin A, or Botox, injections have long been used to safely relax facial wrinkles, but I advise dry eye patients against getting these done for “crow’s feet,” or wrinkles at the corners of the eyes. Botox injections for “crow’s feet” can disrupt the lacrimal functional unit and even prevent normal blink mechanics necessary for wiping the ocular surface and clearing the tear film.

The topical cream Argireline (acetyl hexapeptide-3), sometimes called “Botox in a jar,” is marketed in beauty products as a less expensive, less invasive alternative to injections. However, this component and others like it on the market are neuropeptides that signal facial muscles to relax.

The topical neurotoxins potentially also act on the muscle of Riolan, which is important for facilitating the delivery of meibum from the glands. We have clinically observed that this effect, plus exposure to known human meibomian gland toxic preservatives such as parabens,^2,5 may interfere with the expected results from MGD treatment strategies.

GOING TO GREAT LENGTHS FOR LASHES

OTC eyelash growth serums have proliferated in recent years. FDA-approved prescription Latisse (Allergan) is indicated for hypotrichosis. Be aware that OTC eyelash growth products contain several ocular surface-offending ingredients as well as synthetic prostaglandin analogs (PGAs). However, this is rarely obvious on the packaging, and consumers are not made aware of the risks associated with chronic PGA use. Signs of prescription PGA use include eyelash lengthening, dermatitis, orbital fat atrophy and iris color changes; watch for these signs in your OSD patients and recommend discontinuing the OTC eyelash growth serums.

Additionally, watch for refractory MGD associated with eyelash growth serums. There is a known association between PGAs and MGD; one study found MGD prevalence in glaucoma patients on PGAs was 92% compared to 58.3% in patients using other IOP-lowering drug classes.⁶ Other potential side effects include orbital fat atrophy, discoloration of skin, irises or both and eyelid vascular congestion at the application site. The cosmetics company Rodan + Fields is currently facing a class-action lawsuit for failing to disclose these risks in its isopropyl cloprostenate-containing OTC lash serum.

LEARN TO READ COSMETICS LABELS

Other common synthetic prostaglandins in eyelash cosmetics include bimatoprost, methylamido dihydro noralfaprostal and trifluoromethyl dechloro ethylprostenolamide. Most PGAs contain the root “prost” somewhere in an ingredient name.

In addition, these OTC lash growth products typically contain ingredients, ones that are not present in the prescription product, that can also contribute to dry eye; these ingredients include EDTA, high concentrations of BAK and formaldehyde-donating preservatives such as imidazolidinyl urea, diazolidinyl urea, sodium hydroxymethylglycinate, bronopol and glyoxal (Figure 3). Formaldehyde-donating preservatives are irritating to the cornea, even at low concentrations of just 0.05 ppm. Studies have shown they create dose-dependent cell death in human cell cultures, including corneal, conjunctival and meibomian gland epithelial cells.⁵

Beyond lash-lengthening serums, many women now use synthetic lash extensions, either permanent or temporary, which are affixed to the lash line with some type of adhesive. Formaldehyde from the preservatives in these adhesives can leach onto the ocular surface, causing chemical conjunctivitis and allergic reactions (Figure 4).

Additionally, users of these products may stop cleaning their lid-lash margins for fear of dislodging the extensions, which can contribute to blepharitis and MGD. Magnetic eyelashes avoid the chemical exposures, but eyelash breakage and lash ptosis is common.

CONCLUSION

We must remember that eyelashes serve a functional purpose, not just a pretty one. Their primary purpose is to deflect wind, debris and allergens away from the eyes.

Altering the eyelash length, either with growth serums or extensions, changes the aerodynamics of the eyelashes and alters the lid-to-lash ratio, which can diminish the eyelashes’ protective properties.⁷ Eyelash “perms” alter the mechanical aerodynamic properties of a natural eyelash (think of an umbrella turned inside out in the wind).

We should all pay more attention to potentially damaging beauty practices. At a minimum, ophthalmologists and optometrists should add lash treatments and other beauty practices to the list of multifactorial elements of OSD.

I had the honor of presenting a course on these topics at AAO 2018 alongside Cynthia Matossian MD, Ami Shah, MD, and Wendy Lee, MD. I also offer a list of resources for purchasing safer, less irritating eye makeup or cosmetic products, along with recommended practices.

We can also teach patients to read ingredients labels on cosmetics with the same mindfulness as reading food labels, such as watching out in particular for the root “-prost” and the suffix “-paraben,” as well as “urea”.

By increasing awareness and education, we can help our patients avoid these “vampires on the vanity” that can contribute to MGD and dry eye disease. OM

REFERENCES

1. O’Dell LE, Periman LM, Sullivan AG, et al. An evaluation of cosmetic wear habits correlated to ocular surface disease symptoms. Invest Ophthalmol Vis Sci. 2017;58:E-abstract.
2. Epstein SP, Ahdoot M, Marcus E, Asbell PA. Comparative toxicity of preservatives on immortalized corneal and conjunctival epithelial cells. J Ocul Pharmacol Ther. 2009; 25:113-119.
3. Gouin O, L’Herondelle 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;8:644-661.
4. Lee YB, Kim JJ, Hyon JY, Wee WR, Shin YJ. Eyelid tattooing induces meibomian gland loss and tear film instability. Cornea. 2015;34:750-755.
5. 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.
6. Mocan MC, Uzunosmanoglu E, Kocabeyoglu S, Karakaya J, Irkec M. The association of chronic topical prostaglandin analog use with meibomian gland dysfunction. J Glaucoma. 2016;25:770-774.
7. Amador GJ, Mao W, DeMercurio P, et al. Eyelashes divert airflow to protect the eye. J R Soc Interface. 2015;12:20141294.

About the Author

Laura M. Periman, MD, is an ocular surface disease specialist in Seattle, Wash. Contact her at dryeyemaster@gmail.com. Additional educational content, including a patient handout, can be found at her website, www.dryeyemaster.com . Dr. Periman is also one of the founders of www.dryeyediva.com . She is a consultant for Advanced Tear Diagnostics, Allergan, Eyedetec, Eyevance, Lumenis, ScienceBased Health, Shire, Sun, TearLab, Visant and Umay.