In a recent article, I shared my experiences with and discussed some of the current evidence base for the interaction of cosmetics with the ocular surface.1 This was followed by a sample of cases from practice to underline how common this potentially problematic interaction appears to be.2
This case-based article will highlight a patient I saw recently in my clinic who was suffering symptoms related to a compromised ocular surface and dry eye disease, both of which seemed to be exacerbated by her history of cosmetic use.
Case Study
Presentation
In September 2022, female presbyope, PK, attended my dedicated dry eye clinic for an assessment for the first time, having been a longstanding contact lens patient of mine. Her overall general health was good at presentation. She had been prescribed tamoxifen to minimise future onset of breast cancer.
Ocular history
PK had worn rigid corneal contact lenses for some 40 years, most recently wearing Quasar single vision lenses (Dk 60 from No7). In June 2022, PK underwent bilateral cataract surgery and implantation of posterior chamber intraocular lenses, which left her with monovision. She had a history of longstanding pannus, inferiorly in the right eye.
Clinical findings
Refraction:
- R: -2.25DS (6/6) (N5 unaided)
- L: -0.25 / -0.25 x 180 (6/6) (N5 with +2.25DS add)
TearLab Osmolarity (mOsm/litre)
- R: 315
- L: 320
Non-invasive tear break-up time (seconds) using Topcon Myah (figure 1)
- R: 5.6
- L: 3.6
Tear meniscus height (mm, Topcon Myah)
- R: 0.23
- L: 0.16
Figure 1: (a) Author using the Topcon Myah. (b) Non-invasive tear break-up assessment. (c) Tear meniscus height measurement. Note; images are not for patient PK
Symptoms
PK complained of an increased ‘awareness’ of her eyes, smeary vision in the mornings, and regular fluctuations in her vision throughout the day. She also reported increased epiphora (eye watering) when exposed to the wind and episodes of light sensitivity.
Current management
PK had been using a warm compress for the last year, twice a week on each eye, alongside Systane Complete (preservative-free topical lubricant drop containing propylene glycol, hydroxypropyl guar, nano-sized lipid droplets: Alcon) and an occasional saline eyebath.
Anterior Assessment and Imaging
Closer viewing of PK’s right lower eyelid (figure 2) clearly shows black pigment and debris resulting from her use of eye make-up. Rather than the deposition being randomly accumulated, it can be seen to have accumulated preferentially in the notches formed by her scarred meibomian glands. It is also possible to see all the deposition has formed on or posterior to Marx’s line, where there is potentially more adherence, possibly due to the change in profile from keratinised surface to mucous membrane (figure 3).
Figure 2, 3, 4 & 5 (left to right): Preferential accumulation of debris on right lower lid margin; Marx’s line, highlighted here by lissamine green, delineates the mucocutaneous boundary; low magnification view of the left eye; a higher magnification view of the lower lid margin
Using a more generalised view of the right ocular surface status (figure 4), it was possible to see PK has worn both mascara and external eyeliner. She does not directly apply her make up to the waterline (inner lid margin), and does not necessarily wear an excessively heavy amount. In fact, in my experience, many women (and men) would consider this a normal amount of make-up application. At this low level of magnification, it is simply not possible to see the detail of how the make-up deposition has formed. It is, however, possible to record the generalised, diffuse conjunctival hyperaemia indicative of ocular surface inflammation.
A higher magnification view of the lower lid margin (figure 5) revealed the pigmented deposits sat at the base of the tear prism. This is clearly the area where deposits will be picked up, together with the tear film, on blinking. The lids will then spread the particulate material over the ocular surface, so presenting a potential threat of both direct physical and chemical irritation to the ocular surface.
Figure 6: Cosmetic deposit accumulation at the outer canthus seen in (a) low magnification and (b) high magnification
The accumulation of the cosmetic deposits is most pronounced in the area adjacent to the outer canthus (figure 6). This could, in part, be due to the mechanism of action of the blink, preferentially driving the build-up into the corner of the lid margin.
Figure 7, 8 & 9 (left to right): Cosmetic particles in the tears; Meibography of the (8a) right and (8b) left upper lids; eyeshadow on the upper lid
Using specular reflection to view the first Purkinje image (figure 7), cosmetic particulate debris is clearly visible within the tears. Meibography of each upper lid (figure 8) shows a mild increase in tortuosity, as well as central, frank gland atrophy secondary to meibomian gland dysfunction in both eyes.
A closer look at the upper lid shows that eyeshadow, with glitter microplastics, is still visible, left over from application a few days prior to the appointment (figure 9). What I often term as ‘non-obvious blepharitis’ became more visible for review after a quick attempt at make-up removal during this appointment (figure 10). I often find this form of Demodex blepharitis where frank flakes, crusts or classic collarettes are absent and, instead, what is seen is more of a mound of presumed debris and biofilm around the lash follicle.
Figure 10 & 11: Blepharitis is often masked by cosmetics; fluorescein and blue light assessment of (a) right and (b) left eye. Note the variability of the tear prism and marked LIPCOF
Fluorescein assessment highlighted the tear prism and conjunctival folds (figure 11). It is possible to see the difference in tear prism height in the corneal region compared with the conjunctival region. Centrally, the height is just about acceptable, but this still shows a likely aqueous deficient component given that the conjunctival portion of the tear prim is very low in both eyes. It is also, in part, disrupted by the significant lid-parallel conjunctival folds (LIPCOF) present in both eyes, easily seen as creases in the conjunctiva adjacent to the lid margin.
Figure 12 clearly shows the amount of deposition along the lower lid margins and anterior to Marx’s line. This is likely to comprise cosmetic debris along with dead skin cells and biofilm components. Management with specific lid margin debridement using a golf club spud is clearly indicated.
Figure 12: Lower lid margin of (a) right and (b) left eye requiring debridement
Diagnosis
The diagnosis was made of a combination of conditions:
- Atrophic meibomian gland dysfunction
- ‘Non-obvious’ Demodex blepharitis
- Low grade aqueous deficient component
It is likely that these have been exacerbated by cosmetic use and recent cataract surgery.
Management Plan
In practice:
- Debridement (figure 13)
- Blephex procedure (figure 14)
- Intense pulsed light (IPL) and low-level laser therapy (LLLT) photobiomodulation (PBMT): four sessions booked (figure 15)
Figure 13, 14 & 15 (left to right)
At home:
- Warm compress daily for 10 minutes
- Omega-3 supplement twice a day
- Blephasol Duo: to be used daily, both as a lid cleanser and to help with cosmetics removal
- Systane Complete: twice a day
- Eyes are the Story: recently launched ‘optocosmetics’, which are formulated to minimise ocular impact
Conclusions
Clearly, the patient PK described here has a number of issues, as is often the case with dry eye disease. Working up a logical and methodical approach, to both diagnosis and management, is the key to break the vicious cycle for these patients and achieve tangible and significant results. The importance of cosmetic use in these types of cases must not be underestimated and needs to be addressed as a clearly defined strategy of good management.
- Sarah Farrant is a therapeutic optometrist with a specialist interest in dry eye disease and myopia management practising in Somerset, UK.
References
- Farrant S. The impact of cosmetics on the ocular surface. Optician, 30.09.2022, pp23-29
- Farrant S, Harvey B. Making up is hard to do. Optician, 23.09.2022, pp32-35
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