It is good to end 2022 and begin the new year on a positive note. The interactive CPD exercise designed to encourage discussions about the potential impact of eye make-up upon future contact lens wear success seems to have hit a note with readers.
Indeed, the exercise triggered the greatest response out of all of our 2022 interactive exercises. This does suggest that most of you do, indeed, feel that this is an area well worth consideration and agree with the author of the source material, Sarah Farrant, that eye care practitioners should be able to offer appropriate advice about cosmetics to their patients in contact lens practice.
Background
There is an increasing body of evidence suggesting that many of the components of the cosmetic products routinely applied to the periocular skin and lid margins may have a negative impact upon the tears and ocular surface and, in some cases, have been linked with more serious disease. In the recent CPD, 'The impact of cosmetics on the ocular surface',1 therapeutic optometrist Sarah Farrant explained how her experience, both with patients attending a dedicated dry eye clinic and in more general contact lens practice, supported this view and offered a review of some of the evidence so far published.
One recent study, for example, has highlighted that the prevalence of dry eye disease among women who used eye cosmetics was over 70%,2 much higher than the 5 to 50% among the general population.3 In addition, approximately 25% of participants using eye make-up rarely removed it before sleep. This was shown to be a further significant risk factor in the severity of dry eye. Given these figures, the impact of cosmetic products is something eye care practitioners cannot afford to ignore any more. This was further supported by a series of illustrative case studies published in Optician.4, 5
Case scenario for discussion
You were asked to consider the following patient.
A 22-year-old female attends your practice as she would like to try contact lenses for full time wear. Since starting work in an office, where she is required to use a desktop computer throughout the day, she has found that she increasingly relies on her spectacles as the clarity they give makes work easier. However, she dislikes wearing them because she ‘hates the way I look in glasses.’
Her refraction is:
Figure 1 is an overview of her right eye, the left eye is similar.
Her general health is good, though she does smoke ‘socially’. When asked about allergies, she confirms that she does occasionally suffer hay fever (last episode was some six months ago) for which she ‘takes a tablet from the chemist’.
Also, on occasion, she has had soreness around her eyes with some types of make-up. ‘I now always make sure I use a hypoallergenic brand, because there is no way I am going to stop wearing make-up,’ she states.
Figure 1: Right eye. (a) Low magnification. (b) Upper lid. (c) Lower lid. (d) Lower palpebral conjunctiva
Discuss the following points:
- Would you go ahead with fitting contact lenses and, if so, what would be your first choice to fit (material, design and wear modality)?
- What factors can you identify which might influence future success with contact lens wear?
- Would you mention her cosmetic use if not prompted by the patient – yes or no?
- How would you respond to the patient when she asks, ‘It will be OK to carry on wearing make-up, won’t it?’
Your Discussions
Firstly, all respondents were happy to go ahead and fit the patient with contact lenses. In every case, a daily disposable option was recommended. Interestingly, there was an almost exactly 50/50 split between those recommending a silicone hydrogel option (popular choices were Clariti 1 Day Toric, Acuvue Oasys 1-Day for Astigmatism) and a hydrogel lens option (Dailies Total 1 for Astigmatism, 1-Day Acuvue Moist For Astigmatism).
Everybody felt that the wearing of cosmetics was of significance, but there was some variation in opinion as to the level of intervention regarding this might be appropriate for the eye care practitioner. As the patient themselves highlighted their cosmetic use themself, all of you felt that it was not really a problem offering some advice in this case.
However, were the patient not to have made any mention of their make-up, many of you felt that you would only offer your viewpoint if their make-up application was excessive or adverse changes to the ocular surface or adnexa were already present.
Finally, about half of you gave some indication of the general advice you would give regarding the correct application and removal of make-up for a contact lens wearer to adopt.
As there was such a bounty of opinion with this exercise, I thought it might be interesting on this occasion to show a wider range of your responses than we would normally do. The following quotes reflect the sorts of opinions expressed.
Would you go ahead with fitting contact lenses and, if so, what would be your first choice to fit?
‘With the view to fitting contact lenses, no practitioner nowadays can advocate that a young female should not use cosmetics in conjunction with contact lens wear. Ideally, a lens of silicone hydrogel (offering good oxygen permeability for long office hours) and of toric design (for the patient’s astigmatic prescription) with a daily wear modality (for the cosmetic usage). Monthlies may suffer depositions.’
‘We ideally would like to use a lens that is non-ionic so does not attract particles to the lens surface, which would have an impact on the vision and the comfort of the lens.’
‘I would go ahead in fitting contact lenses to this patient. The picture of her right eye (figure 1) shows no red eye. The eye make-up is not stuck to the eye lashes on the bottom lid. The meibomian glands look as if they are functioning properly. Silicone hydrogel contact lenses provide high oxygen content to the eye. A daily lens is chosen as this will stop make-up build-up on the lens, thus reducing the toxic effect of cosmetics to the eye. Wear time for the contact lens should be nine to 12 hours a day five days of the week.’
‘We agreed we would go ahead and fit contact lenses to this patient. The most suitable lens modality is a daily disposable lens as this will help to reduce the risk of inflammation as a consequence of make-up build-up. We discussed various daily disposable lenses and decided a hydrogel lens surface would be the most suitable to repel the non-ionic deposits. It is also a thinner lens compared to a silicone hydrogel, which would help to reduce the likelihood of developing allergic conjunctivitis related to hay fever. While the patient would prefer to wear lenses full time, we would advise on a reduced wearing schedule.’
What factors can you identify which might influence future success with contact lens wear?
‘The astigmatism is a factor that would influence success with contact lenses (CLs). It is critical that the lenses are comfortable and stable, remaining in place irrespective of head and eye movements. Additionally, her hay fever, along with heavy make-up use is another good reason for fitting a daily disposable.’
‘The main factor that might influence future success with CL wear is dry eye. The patient is a smoker and wears heavy make-up daily. So, advising a daily disposable lens in conjunction with lid care will help to ensure CL success. For example, using Blephawipes to ensure full make-up removal and the likelihood of blepharitis will help to stabilise the tear film. Additionally, a preservative-free dry eye drop will aid comfort. Keeping wear time reduced and wearing glasses when at home, even though the patient does not enjoy wearing glasses, will help to ensure that CL wear is comfortable when away from home. Working in an office environment will impact on the dry eye too. So, a water gradient lens will help to avoid the dry eye feeling. The patient has good motivation to follow the advice for CL success as she reports hating wearing spectacles and, as she is increasingly reliant on her prescription, she is likely to be more motivated to wear CLs over specs.’
One respondent noted: ‘The meibomian glands showing on the inferior tarsal plate look slightly tortuous and inflamed, so she might have some evaporative dry eye.’
Would you mention her cosmetic use if not prompted by the patient – yes or no?
‘Addressing the cosmetic usage would not deem to be a routine stipulation. However, excessive applications might be worth mentioning.’
‘Yes. In this case the patient has already drawn attention to her use of cosmetics.’
‘I would mention the use of cosmetics to the patient. I would advise her to insert her contact lenses before applying any make-up to limit exposure. Never to apply eyeliner on the inner waterline of the eyelid, or between the eyelashes. Always remove contact lenses before using any make-up remover or face wash. I would explain to the patient that false lashes can also cause a risk to the ocular surface. I would advise the patient to use dry eye-friendly cosmetics. Some products, such as eyeliner or mascara, contain carbon black, which has been found to be carcinogenic. Other preservatives (such as phenoxyethanol) are toxic to the meibomian gland epithelial cells. By informing the patient of possible toxic effects of certain cosmetics she should be more careful of the cosmetics she uses.’
‘It will be OK to carry on wearing make-up, won’t it?’
‘Of course, you are able to continue using your make-up; just take care with your contact lenses. Always apply your contact lenses first, before you apply your make-up. This reduces the risk of particles getting onto the lens surface and into your tear film. Then, remove your contact lenses before removing your make-up.’
‘Clearly, she is not going to give up (make-up) use and it is better that we encourage her to apply it correctly, rather than offer a counsel of perfection she will not follow. We also discussed our experience of make-up and CL wear and said we have seen many examples of badly applied make-up soiling lenses, contaminating the tear film and causing ocular irritation. We felt this patient was likely to be successful as she applies it with care and will likely comply with removal and replacement guidelines.’
Sarah Farrant Adds
My top 10 points to consider regarding the wearing of cosmetics are as follows:
- Be realistic; patients who currently wear any forms of eye make-up are unlikely to want to give it up completely
- Advise patients to remove all make-up at the end of the day with a good lid hygiene product (such as those to treat blepharitis)
- Be aware; eyeliner, mascara or eyeshadow can mask or mimic blepharitis (figure 1b). Take a careful look during your consultation and don’t be afraid to ask the patient to remove their eye make-up for a better look if necessary
- Don’t forget the men’s beauty market has grown significantly in recent times
- Good patient education is paramount
- Labels such as ‘plant-based’, ‘natural’, ‘organic’, ‘vegan’, and ‘ophthalmologist-tested’ do not equate to ocular surface safety
- Be extra aware of the implications of cosmetics for contact lens wearers
- Consider enhanced antimicrobial management in cosmetics users with advice on daily hypochlorous acid sprays onto the lids and periorbital skin
- Alternatives to daily cosmetics, such as false lashes, also put the ocular surface at risk
- Consider recommending or even stocking dry eye friendly cosmetics (such as the ‘Eyes Are The Story’ opto-cosmetic range)
- 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
- Albdaya NA et al. Prevalence of dry eye disease and its association with the frequent usage of eye cosmetics among women. Cureus, 2022;14(7):e27142.
- Gomes JAP et al. TFOS DEWS II: Iatrogenic report. The Ocular Surface, 2017, Volume 15, Issue 3, pps 511-538
- Harvey B, Farrant S. Making up is hard to do. Optician, 23.09.2022, pp32-35
- Farrant S. Making up is still hard to do. Optician, 11.11.2022, pp20-22