Blepharitis

Blepharitis can be associated with cosmeticprocedures such as lash extension, lash tinting, and lash serum use. 

“We should heighten our suspicion when we see patients coming in with longer lashes, whether they’re artificial or due to lash lengthening serums,” said Dr Venkateswaran. “You’re going to see very characteristic collarettes that form at the base of the eyelashes. If the eyelashes are artificially too long, they’re not doing a good, natural job at removing the debris, which they’re supposed to be doing on a daily basis. When I see that clumping, collarette-like formation, I tell my patients that they have to start improving their eyelid hygiene.” 


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There’s no doubt that eyelashes are having a moment. As Dr Venkateswaran put it, “Especially with COVID, people are looking at your eyes. One of the biggest things I’ve seen people work on are their eyelashes — whether it be through mascara or artificial eyelashes or using lash serums to help extend their lashes.”

“I’m seeing a lot of it, and I’m seeing the whole range of procedures,” she added. “[But] I think the challenge with artificial lashes is that they’re often too long. The optimal lash length is supposed to be one third the width of the eye. If you have lashes that are extremely long, they’re not filtering dust particles; they’re probably just accumulating them.” 

Lash lifts and extensions are particularly trendy and can be performed by estheticians right in the salon. Lash lifts are often described as a perm for the eyelashes, lifting the lashes into a perma-curled state. Unlike the chemicals once used to perm hair, those used to perform lash lifts are gentler.16 Lash extensions, on the other hand, are natural fibers — typically mink, synthetic silk, or synthetic mink—that are attached using a permanent adhesive to the natural eyelash.17

Lash serums — products that hydrate and condition the natural lashes and stimulate hair follicle growth — are slightly more complicated: there is only one Food and Drug Administration (FDA)-approved lash serum available, bimatoprost ophthalmic solution, 0.03% (Latisse®, AbbVie).18,19 However, dozens of products exist claiming to use ingredients such as biotin and peptides to achieve over-the-counter results.20 For the most part, Dr Dweck said, these procedures seem to be fairly safe. But there is currently no way to predict which patients might have sensitivities to these products.  

“The glue used for lash extensions can cause allergic reactions on the eyelid skin and chemical injury to the eye if it gets into the eye itself,” said Dr Haberman. “The weight of false lashes can cause traction and breakage of the natural eyelashes, and the chemicals used in lash lifts can also cause lash breakage if left on too long.” 

And while estheticians say that the adhesives are safe, many glues used by salons can be toxic and cause irritation. 

“I recently saw a patient who developed chronic follicular conjunctivitis from having artificial lashes,” said Dr Venkateswaran. “I don’t know if it’s from the glue or the natural lashes that broke and embedded into the conjunctiva, but the patient has experienced recurrent episodes of inflammation for almost 3 months. She came to me for a third opinion: I can only pinpoint one thing that’s not old, and it’s the lashes.”

Although complications can be common, reputable salons do provide clients with cleaning products and instructions on how to use them. 

“When you do go and get these procedures done, they go over ways of keeping the area clean and give you special products in order to do so,” said Dr Di Meglio. 

The problem arises when patients neglect these cleaning regimens and opt to not touch their lashes. “I see a ton of people who come in with glued on lashes; they don’t touch them, [which] fosters a lot of gunk around the lashes which can lead to blepharitis [and other] bacterial growth which can then get into the eyelids, causing issues.” 

Contact Dermatitis and Allergic Conjunctivitis

For the allergy-prone, eye makeup use requires conscious, constant awareness about the cosmetic products being used. Mascara, eyeliner, and lash lifts, extensions, and serums have all been linked to allergic conjunctivitis, as well as the preservatives in our makeup products themselves. 

“People can be allergic to the preservatives in makeup products, which can cause eyelid skin irritation, redness, and edema,” said Dr Haberman. If certain chemicals make contact with the ocular surface itself, irritation, corneal abrasion, and inflammation may also occur. 

“I have [also] seen patients with bad eyelid reactions to lash glue that caused such a large amount of swelling that they couldn’t even open their eyes,” she added. Dr Dweck is also familiar with “major allergic episodes” associated with lash procedures, resulting in the loss of the patient’s own natural lashes and inflammatory conditions. 

BAK — benzalkonium chloride — and formaldehyde preservatives have also been identified as primary drivers of toxic effects on the ocular surface, and are commonly found in products such as mascara, eye shadow, eyeliner, and eye makeup remover.21 They’re used to prevent microbial growth, but recent research results found that both BAK and formaldehyde are responsible for dose-dependent changes in the “morphology, survival, and proliferation and signaling ability of immortalized human meibomian gland, corneal, and conjunctival epithelial cells.”21

On the other hand, allergic contact dermatitis of the eyelid has been associated with 7 common allergen groups, including metals, shellac, preservatives, topical antibiotics, fragrances, acrylates, and surfactants.22 Management of eyelid allergic contact dermatitis relies on the accurate identification and “proper avoidance” of allergens—the most straightforward and effective cure for the condition. 

Allergic contact dermatitis specifically associated with makeup use is, according to researchers, “probably the most common reason [that] patients present for patch testing.”23 Facial dermatitis — frequently involving the eyelids — can stem from shampoo, conditioners, facial cleansers, nail polish, acrylic nails, makeup sponges, and makeup itself.23

“Allergic reactions respond very well to topical steroids, as well as to topical antihistamine drops,” said Dr Venkateswaran. “That’s something I prescribe pretty commonly.”

The Importance of Ocular Hygiene

For patients experiencing ocular surface conditions associated with eye makeup use, the news isn’t all bad: all of the physicians interviewed by Ophthalmology Advisor agree that proper ocular hygiene can go a long way towards rectifying any potential problems before they’re unable to be fixed. 

“The best line of treatment is just proper ocular hygiene,” Dr Di Meglio said, especially for patients who wear contacts with their makeup. “With contact lenses in general, having the best ocular hygiene is important; you don’t want anything to brew behind that contact lens and cause something that could be potentially vision threatening.” In addition to proper daily contact lens cleaning, people should ensure their hands are as clean as possible when handling lenses and applying makeup. 

The pigment from eye makeup that can end up on the ocular surface can also make its way onto the surface of the contact lens, said Dr Venkateswaran, “potentially creating a biofilm or reservoir for bacteria and infection.” 

She advises her contact lens patients to apply makeup first and ensure that all debris is removed before placing the contact lens. However, if all debris isn’t clear, there’s a chance a fleck may end up trapped beneath the contact, “which can be excruciating and can cause problems,” said Dr Dweck. “[Contact lenses] aren’t contraindicated by any means, but patients just need to be aware, and to be careful with their contact lenses and makeup.” 

Best Practices

Treating patients with ocular surface conditions resulting from eye makeup use can be complex, but there are a few best practices that treating physicians can keep in mind. 

“If the patient is complaining of irritation of the eyes, look at the lids, not just at the eye,” said Dr Dweck. “Look at the meibomian glands; look at the orifices of the meibomian glands. Check for dry eye, if there’s any loss of lashes, any swelling of the eyelid. Some of these [symptoms] may be subtle.” 

Dr Venkateswaran encourages her fellow physicians to identify the cause of the problem. “Is it the location of the makeup application, the type of makeup, [or] a combination of makeup and contact lenses?” Whatever the cause, the goal is, ultimately, to remove the offending agent and offer the patient alternatives that will minimize future risk. 

“In general, you want to advise the patient to check the ingredients on their makeup, make sure they’re cleaning their brushes and sponges, and not sharing makeup products. Make sure the products they’re using aren’t expired, and make sure you aren’t dipping your fingers multiple times into a cream, then placing it around the eyes.” 

An alternative might be encouraging patients to wear cream- or liquid-based products instead of using powders and pencils, said Dr Haberman, “because they are less likely to wind up inside the eye.” She also emphasized the importance of removing makeup before bed; eyes rubbing against a pillow can facilitate the migration of makeup onto the ocular surface. 

Patient education also goes a long way—especially when it comes to making sure the patient is removing all of their makeup on a nightly basis. “Encourage them to do warm compresses and lid scrubs [and] use artificial tears to get anything out of the eyes or to help with dry eye,” said Dr Di Meglio. “As long as patients are careful with it … I wear eye makeup every day and just make sure to take it off at night.” 

“What I often tell my patients when they come into the office asking for advice about what they should be doing with their makeup, I tell them that the best thing is to, at the end of the day, take just five minutes,” said Dr Venkateswaran. “Remove eyeliner, mascara, and foundation around the eye, and wash the skin of the face.”

“If you take a few minutes to wash off that makeup,” she said, “it’ll save you a lot of headaches in the future.”

References 

  1. Wang MT, Craig JP. Investigating the effect of eye cosmetics on the tear film: Current insights. Clin Optom. 2018;10:33-40. doi:10.2147/OPTO.S150926
  2. Eye makeup market size, share & trends analysis report by product (mascara, shadow, liner, pencil, brow), by distribution channel (online, offline), by region, and segment forecasts, 2019-2024. Grand View Research. https://www.grandviewresearch.com/industry-analysis/eye-makeup-market. Published April 2019. Accessed July 5, 2021. 
  3. Sabanoglu T. U.S. eye cosmetic sales 2019, by segment. Statista. https://www.statista.com/statistics/538035/us-eye-cosmetic-sales-by-segment/. Published November 30, 2020. Accessed July 5, 2021. 
  4. Franck C. Fatty layer of the precorneal film in the ‘office eye syndrome’. Acta Ophthalmol. 1991;69(6):737-743. doi:10.1111/j.1755-3768.1991.tb02052.x
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  6. What is tightlining? Everything you need to know about this invisible eyeliner technique. L’Oreal Paris USA. https://www.lorealparisusa.com/beauty-magazine/makeup/eye-makeup/invisible-eyeliner-how-to.aspx. Accessed July 5, 2021. 
  7. Oliver D. What ‘tightlining’ is, the makeup trick that’ll make your eyes pop. HuffPost. https://www.huffpost.com/entry/tightlining-eyeliner-makeup_n_56278b7ae4b08589ef49d037. Published October 21, 2015. Accessed July 5, 2021. 
  8. Sędzikowska A, Bartosik K, Przydatek-Tyrajska R, Dybicz M. Shared makeup cosmetics as a route of Demodex folliculorum infections. Acta Parasitol. 2021;66(2):631-637. doi:10.1007/s11686-020-00332-w
  9. Liu J, Sheha H, Tseng SCG. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010;10(5):505-510. doi:10.1097/ACI.0b013e32833df9f4
  10. Karakurt Y, Zeytun E. Evaluation of the efficacy of tea tree oil on the density of Demodex mites (acari: Demodicidae) and ocular symptoms in patients with demodectic blepharitis. J Parasitol. 2018;104(5):473-478.
  11. Salva K, Le JT, Pucker AD. Tea tree oil for Demodex blepharitis. Cochrane Database Syst Rev. 2020;6(6):CD013333. doi:10.1002/14651858.CD013333.pub2
  12. Frame K, Cheung IMY, Wang MTM, et al. Comparing the in vitro effects of MGO™ Manuka honey and tea tree oil on ocular Demodex viability. Cont Lens Anterior Eye. 2018;41(6):527-530. doi:10.1016/j.clae.2018.06.006
  13. Alevi D, Donnenfeld E, Perry H. Mascara-induced conjunctival pigmentation. JAMA Ophthalmol. 2016;134(11):e162720. doi:10.1001/jamaophthalmol.2016.2720
  14. Gupta N, Bansal S, Gandhi A. Endoscopic view of mascara laden lacrimal sac with canalicular involvement. Indian J Ophthalmol. 2019;67(2):279. doi:10.4103/ijo.IJO_1348_18
  15. Donaldson DD. Mascara pigmentation of the conjunctiva. Acta Ophthalmol. 1969;81(1):124-125. doi:10.1001/archopht.1969.00990010126017
  16. Brucculieri J. What exactly is a lash lift, and how is it done? HuffPost. https://www.huffpost.com/entry/what-is-an-eyelash-lift_n_5c362379e4b035aceba49acc. Updated January 10, 2019. Accessed July 5, 2021. 
  17. Rhue H. Every question you’ve ever had about lash extensions, answered. Byrdie. https://www.byrdie.com/lash-extension-tips. Updated November 17, 2020. Accessed July 5, 2021. 
  18. Nazish N. Why you need an eyelash serum (and the best lash growth serums that actually work). Forbes. https://www.forbes.com/sites/nomanazish/2021/12/31/why-you-need-an-eyelash-serum-and-the-best-lash-growth-serums-that-actually-work/?sh=7fb3e31d66e9. Published December 31, 2020. Accessed July 5, 2021. 
  19. Hazanchuk V. What you should know about eyelash growth serums. American Academy of Ophthalmology. https://www.aao.org/eye-health/tips-prevention/latisse. Published December 5, 2019. Accessed July 5, 2021. 
  20. Berohn K, Velasco P. The 15 best eyelash growth serums that actually work. Good Housekeeping. https://www.goodhousekeeping.com/beauty-products/g27511777/best-eyelash-growth-serums/. Published April 26, 2021. Accessed July 5, 2021. 
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  23. Zirwas MJ. Contact dermatitis to cosmetics. Clin Rev Allergy Immunol. 2019;56(1):119-128. doi:10.1007/s12016-018-8717-9

This article originally appeared on Ophthalmology Advisor