When beauty is the beast, part 1
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“Dr. White, you know more about eye makeup than any other straight man in the world!”
I hear this several times every week in my daily clinic as I see women (and men) who have symptomatic dry eye disease (DED) and arrive at my slit lamp wearing all manner of makeup. Kinda unexpected when you think about it, me being a rather generic, cis-hetero middle-aged man. On the one hand, wearing all of that makeup can make it challenging to see what is going on underneath. On the other hand, however, nothing is quite as telling about how your patient is faring out in the wild than to have them come in made up as they would be on any other day.
The real flip side, of course, is that you discover the fastest way to create an ex-patient: Tell them they cannot wear eye makeup.
In all honesty, what I know about eye makeup is mostly the sum of my observations over the past 25 years, the accrued common sense of a paid observer seeking to help a population of patients who skew strongly female. Sadly, the reality is that until I sat down to write this column, I did not realize just how much good information is out there about the bad stuff that cosmetics do to our patients’ eyelids, eyelashes and ocular surface.
From what I have been able to discover, two of the ophthalmologists who did much of the earliest work in this area are Cynthia Matossian, MD, and Laura Periman, MD. Both of these luminaries are among my closest professional colleagues; it is no surprise at all that they are leaders here. For years, Cynthia has lectured on the trauma visited upon eyelashes by the cosmetics industry, sharing images that are simply appalling. Laura, notably in her presentation at Hawaiian Eye in 2020, has assembled the most comprehensive list of noxious elements in mascara, eyeliners and lash “serums,” along with providing an understanding of why these substances are so harmful. Others have certainly made contributions, but Drs. Matossian and Periman have led the charge.
There are physical attributes to cosmetics that are harmful to all ocular structures. The easiest and sadly most common example is the use of eyeliner along the lid margin, the so-called “waterline.” We prescribe all kinds of treatments to keep the meibomian glands open, and with a gentle swipe, our patient does exactly the opposite. Putting eyeliner along the lid margin essentially dams up the meibomian glands. This obviously prevents the egress of meibum, leading to increased evaporation and subsequent surface inflammation and all that comes from that. In addition, painting over the gland orifice traps all manner of bacteria under the eyeliner and inside the gland. From here it is a short step to increased endotoxin and biofilm creation and the mischief they go on to produce.
So-called permanent eyeliner is hardly a benign alternative. The ink used to tattoo the lid just below the lash follicles can contain substances that are toxic to the follicles themselves. Many of the ingredients are known allergens that can lead to chronic swelling and redness of the lids. Of particular interest to DED doctors is the fact that the ink often migrates inward, eventually invading the meibomian glands and leading to inflammation, ineffective meibum and, of course, the evaporative DED that results.
Likewise, the physical presence of mascara on the eyelashes has deleterious effects. The sheer weight of the mascara can distort the position of the eyelashes and have a negative effect on both the protection afforded to the eye by the lashes as well as the airflow patterns across the ocular surface. Even a subtle increase in flow across the ocular surface increases dryness. Incomplete removal of mascara leads to inflammation in the lash follicles, and when the mascara falls into the eye, it causes a macrophage invasion that can leave the tarsal conjunctiva looking like a bad leopard-skin knockoff.
But it is the ingredients in mascara (and eyeliner) that are really the bad actors. Have you ever actually read the list of ingredients in a standard commercial mascara from a well-known cosmetic company? Yuck! According to Dr. Periman, preservatives such as benzalkonium chloride are ubiquitous. There must be a dozen alcohols listed in various formulations, all of which are pro-inflammatory. It gets worse. Most cosmetics used around the eye contain either formaldehyde or so-called “formaldehyde donors” such as sodium hydroxymethylglycinate. You remember formaldehyde, right? The stuff that kept your cadaver in anatomy class from melting? Yah, that stuff is in eye makeup.
We have yet to get to the really bad part. Scary, eh? The pursuit of super long eyelashes is nothing short of a disaster. Eyelash extensions in boutiques and at-home false eyelashes all weaken existing lashes. Just the weight of the extensions can cause the natural lash to become brittle and break. “False” lashes applied just above the lash line actually damage the tiny micro-lashes that would otherwise go on to develop into new lashes. All of the glues that are used are toxic to the eyelid skin, lash follicles and meibomian glands. Commonly used cyanoacrylate glues are formaldehyde donors, and many contain latex, a powerful allergen. Incompletely removed glue leaves a line of debris along the base of the eyelashes, causing increased frequency and severity of meibomian gland dysfunction and Demodex infestation, leading to ...
Well, you know.
Want more? Of course you do. Allergan was not the only company to notice that patients on Xalatan (latanoprost, Viatris) had ridiculous lash growth. The fact that Lumigan (bimatoprost ophthalmic solution 0.01%, Allergan) had the exact same effect led directly to the introduction of the original “lash serum,” Latisse (bimatoprost ophthalmic solution 0.03%, Allergan). Of course, there is nothing wrong with using Latisse unless you happen to get some of the other things that so many users of Xalatan (and Lumigan and travoprost and all of the generics) also got. You see this all the time in your DED clinic. Bright red lid margins. Dark pigmentation in the skin above and below the eyelids. Changes in the quality of meibum and the eventual evaporative DED that accompanies this.
What does this have to do with cosmetics? It turns out that there is little regulation of what goes into makeup. While they do not use FDA-approved prostaglandins, mostly for fear of being sued by a pharmaceutical company, almost every “lash serum” available from established cosmetic companies actually contains a prostaglandin analogue. If you look carefully, you can find it, the little “prost” tucked into the middle of a mishmash of organic chemistry the likes of which kept you up at night as a pre-med student. Like “trifluoromethyl dechloro ethylprostenolamide” — you have to get through 12 syllables before you get to that “prost” booby trap.
And that is from the honest cosmetic makers! EyEnvy in Australia and Canada did not list the prostaglandin analogues in its products; once discovered, the products were eventually taken off the market. Rodan + Fields failed to disclose that its Lash Boost product contained isopropyl cloprostenate (there is that little “prost” devil again); the company denied guilt but settled a class action lawsuit for $38 million.
It all sounds pretty depressing, eh? Fear not, there is hope. Next month in part 2, I will share some relatively easy, common-sense things that you and your patients can do to reduce the DED burden of their cosmetics. Even better, I will share the stories of some of the eye doctors who are taking it upon themselves to produce makeup that is not harmful to eyelids, eyelashes or the ocular surface.
Just wait until my patients see how smart I am now!
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
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