To complement this week’s CPD feature on cosmetics, this article shows a range of patients where, in some capacity, their use of cosmetics has contributed to a problem or, conversely, appropriate advice about a cosmetic has helped with the management of the patient.
Case 1
Presentation
Fifty-four-year-old female, DC, attended for a routine eye test, her first for three years. Over this time, she had noticed her reading vision had deteriorated to the point that, reluctantly, she had been using a pair of readymade readers (+1.50DS) for evening reading. She hated wearing these as she felt spectacles ‘ruined my looks’. Otherwise, her vision was good and there were no reported asthenopic symptoms.
DC worked in a canteen in a busy office block and spent the work day moving between a very hot and humid environment to a cool, dry air-conditioned environment. Not only was this another reason to avoid spectacles (‘they keep steaming up’), but over the summer she had found her eyes starting to become ‘stingy’ and her vision ‘misty when I blink’. Things had improved a little since, one month ago, she had ceased to use eyeliner but, hating no make-up, she still used a mascara (applied and removed daily).
General health was good, no medications were taken and all other health and history details were unremarkable. Because of her hectic job, she spent most weekends on country walks to ‘wind down.’ She tended not to use sunspecs, again because she ‘doesn’t like the look.’
Main concern
Halfway through the slit-lamp examination, DC suddenly sat back and asked ‘what do you think it is?’ Seeing my puzzlement, she said that her main worry was the increasing ‘bagginess’ of the periorbital skin beneath the brow, especially over her right eye. She then went on to describe how her mother had, in her sixties, had the same thing happen and that, eventually, her skin drooped so much that she paid for cosmetic surgery. DC wanted an opinion on this; specifically, whether such surgery for her now would avoid the later changes that had so much upset her mother.
Relevant clinical findings
Visions: R & L; 6/4
Refraction:
- R: +0.25/-0.25 x 95 (-0.1)
- L: +0.25/-0.25 x 80 (-0.1)
- R&L: N5 with +1.50
Binocular status:
- Ortho distance and 3Δ XOP @ 40cm, good recovery
- Convergence to nose
- Motility to nose
IOP:
- 15mmHg R&L GAT @ 09.56
Full threshold fields and OCT: normal findings
Ophthalmoscopy: unremarkable and healthy throughout
Anterior:
- Skin over superior orbital rim slightly elevated, more noticeable on right, and slightly flaccid on palpation (figure 3)
- No evidence of ptosis either eye
- Lid margins show grade 1 meibomian gland dysfunction and grade 1 anterior blepharitis (Efron, figure 2)
- Fluorescein break-up time: eight seconds R@L (figure 3)
Figure 1, 2 & 3 (Clockwise from top): Skin over superior orbital rim appeared slightly swollen, was flaccid and loose on palpation, and the superior lid crease seemed exaggerated; Grade 1 MGD (Efron grading); Fluorescein break-up time of eight seconds
Management
This patient has presbyopia, low grade MGD and blepharitis affecting tear quality and comfort, and has early dermatochalasis of the superior orbital area.
I suggested:
- Use of Blephasol Duo lid treatment, twice a day for a month minimum. With good compliance, this can be effective in the management of low-grade blepharitis and MGD and, as a consequence, low grade tear instability.1
- I suggested that, if wearing eyeliner in future was important for her, I would send her details of products known to be inert in contact with the skin. I emphasised that this should only be used anterior to the lash line.
- I explained the nature of presbyopia and the increasing need for a near correction. Because of her working environment and her simple refractive error, I suggested she consider a trial of soft multifocal contact lenses. This option appealed to her, so the following trial lenses were put aside:
- Trial lenses: Clariti 1 day multifocal, silicone hydrogel, daily replacement: R +0.25 LOW, L: +0.50 LOW
- I explained that the area she was concerned with was a common change in most people, usually starting around the fourth to fifth decade, known as dermatochalasis. This is due to excess eyelid skin, muscle or fat, which commonly occurs above the upper lid. In time, the subdermal elastic tissues and collagen fibres around the eyes are unable to maintain their elasticity, losing their normal shape and structure. As the skin tissues begin to stretch and expand, excess skin starts to hang or droops downwards, further causing thinning of the skin, wrinkling and/or drooping. I was able to demonstrate this with my own facial appearance (figure 4).
- I explained that any cosmetic intervention for aesthetic reasons was always a personal choice and, though my advice was that, at this stage, prophylactic measures seemed the most sensible choice, ultimately the final decision was hers and she may wish to ask the opinion of a cosmetic medical specialist. And if DC was ever to feel that the change was in anyway interfering with her quality of life, that might be the time to consult further about possible surgical intervention.
- I reassured DC that dermatochalasis can only be considered to be inherited in that anatomical shape and skin distribution tends to be familial. It might be reasonable, therefore, to expect some progression along the lines her mother had experienced, but this was by no means certain. However, any preventative measures for this progression should be seriously considered now. These were discussed with DC.
Figure 4: Appearance of dermatochalasis in a 57-year-old male
Discussion
Dermatochalasis cannot be prevented, but there are steps that anyone and everyone can take to reduce its progression. Since dermatochalasis is a skin ageing issue, these steps revolve around one theme: good skin care.
To reduce the risk of developing dermatochalasis or minimising the risk of progression, the following steps can help:
- Do not over-wash your face, as this can create more skin problems.
- Keep your skin well moisturised: this will help keep it healthy. For DC, I recommended a neutral aqueous cream for regular use. I also suggested she maintained good hydration at work.
- Avoid smoking (not relevant here), excessive drinking (relevant), and other causes of dehydration
- Use a high factor sun cream (sensitive formulation) when outdoors from now on, and reconsider wearing good quality, large eye sunspecs, both to help with the skin and to maintain good eye health.
Case 2
Presentation
Patient ME, a 56-year-old female, attended for a dedicated dry eye clinic appointment. This had been prompted by her history of symptomatic dry eye of some years, which had yet to be adequately addressed.
As is recommended before a full dry eye disease examination, ME claimed to have not worn make-up for three days and was convinced she had removed it thoroughly three days ago. For an accurate assessment of structures such as the meibomian glands as well as analysis of tear patency without any leached in chemicals, make-up removal is important prior to an appointment.
Initial observation
It was immediately obvious, even to the naked eye, that ME still bore traces of make-up on her lids (figure 5).
Figure 5: Initial view of the (a) right and (b) left eyes suggested the presence of residual make-up on the lids and around the lashes. Also note the nasal and temporal pinguecula, causing some discolouration, the irregularity of the inferior lid margin, suggesting a longstanding history of blepharitis. Also, when looking near the corneal reflex on the left eye, note the significant debris within the tears
Slit-lamp examination confirmed these suspicions:
- Mascara residue on upper lashes (figure 6), greater concentrations temporally in both eyes
- Scattered carbon debris around lower lid margin and evidence of significant tear debris (figure 7)
- Pigment staining around some upper lash follicles (figure 8)
(Left to right) Figure 6: Mascara around lashes and on inter-lash spaces; 7) Scattered eyeliner debris around lower lid margin (red circles), and significant debris within the tears, best seen via specular reflection near the bright corneal reflex (white arrow). Also, note the clearly demarcated top of the tear prism, indicating tear volume is likely to be above average value; 8) Yellow pigment residue, suggesting longstanding contamination of the affected lashes; 9) a) BlephEx system with replaceable heads. (b) Blephex application on a patient
Management
Before further assessment could be carried out, the lid margins and lashes had to be thoroughly cleaned, debris removed and skin exfoliated. This was performed easily and quickly using a rotary medical grade micro-sponge system; BlephEx (figure 9).
With just one application of the BlephEx to each lid, the surfaces were fully cleaned and assessment could begin (figure 10).
Figure 10: Lids of patient from figures 5 to 8 after BlephEx treatment
Case 3
Presentation
CB, a 26-year-old female, attended for a routine eye test just three weeks before her due date to give birth. Her main concern was occasional periocular irritation, most noticeable on the surface of the upper lids. CB said these areas occasionally ‘flared up’, and became ‘itchy and blotchy’. As is so often the case, by the time her appointment came round, both areas were calm and quiet.
Main concern
History and symptoms revealed that CB had no visual or ocular health concerns and this was confirmed by the subsequent test. Indeed, she confessed to having booked the test primarily to relieve the boredom of the last days of pregnancy.
That said, one point CB became clear as she was questioned about her itchy skin and a history of atopy. It seemed that her recent skin irritation was something new and had never happened prior to pregnancy. However, for some years, now, CB has had to limit her use of eyeliner and mascara as, on several occasions in the past, they had resulted in itchy or sore eyelids.
Relevant clinical findings
Slit lamp assessment revealed grade 1 blepharitis around all lash lines (figure 11). All else (lids, adnexa, tears, ocular surface and anterior eye) appeared healthy. Though somewhat dry, there was no evidence at examination of signs of skin irritation on the upper lid brow areas (figure 12).
Figure 11 (top): Grade 1 blepharitis; 12) External lids. (a) temporal, (b) nasal. Left (c) nasal, (d) temporal. No evidence of dermatitis (bottom)
Management
I explained to CB that, during pregnancy, it is very common for women to experience some skin itchiness and irritation, with up to 90% having some experience of this at some point.2 CB’s symptoms suggested sporadic, transient episodes of atopic dermatitis. Maintaining good hydration, and the use of an inert moisturising cream or gel would seem appropriate at this stage, and she was reassured not to worry. Obviously, were any new symptom of concern to appear at this important time, it was important for CB to discuss this with her GP.
Regarding CB’s keenness to try any new eyeliner or mascara that might be better tolerated by her reportedly sensitive eyelids, I was able to present (on a trial basis) some of the Eyes Are the Story range of ophthalmologist-formulated cosmetic products now available in the UK (figure 13). Care was taken to ensure that CB only applied the eyeliner outside the lash margin (figure 14) and that mascara was applied sparingly (figure 15).
Figure 13: Eyes Are the Story cosmetics, including mascara, skin cleanser, moisturising serum and eyeline
Figure 14 & 15 (left to right): (a) CB applying eyeliner, (b) eyeliner applied; Eyeliner anterior to lash line only (right)
The plan is to review CB, ideally after three months once, hopefully, her baby is born and she has had a chance to try out the make-up.
- Eyes Are the Story is distributed in the UK by Positive Impact and further information is available at eyesarethestory.com.
References
- Guillon M et al. Symptomatic relief associated with eyelid hygiene in anterior blepharitis and MGD. Eye and Contact Lens, 2012, Sep; 38(5): 306-12
- Balakirski G, Novak N. Atopic dermatitis and pregnancy. Journal of Allergy and Clinical Immunology, 2022, VOL 149, Issue 4, 1185-1194
- If you have a case study of interest, why not send it to us? If suitable, it could earn you an interactive CPD point and be considered for publication. For further details, go to www.opticianonline.net/cpd-archive/6348.