This article considers the impact of cosmetic products upon ocular integrity and the implications for patients with regard to reducing risk of adverse reaction and ensuring successful contact lens wear
Using cosmetic products around the eyes for adornment is a process that dates back to Ancient Egypt.1 The earliest forms of eye cosmetic products were derived from botanical sources such as henna, cedar or sycamore sawdust, burnt almonds, along with minerals, or animal sources, for example honey, milk and blood.1 Modern day, commercially available cosmetics are vastly different to their historical counterparts but the motivations behind their usage remain the same: eyes remain the most important aspect of facial attractiveness.2
Modern day eye cosmetic products include eye shadow (either powder or cream), eyeliner (liquid, pencil or gel), mascara (waterproof or not), concealer (cream or liquid) and eye creams;3 these products might be applied to the skin immediately surrounding the eyes, millimetres away from the lid margin (eye shadow, eyeliner, concealer and eye cream) or to the eye lashes (mascara). The desired ability for cosmetic products to reside on skin for longer periods has led to the development of ‘long-lasting’ formulations. Personal preference dictates which product a consumer elects to use, and the way in which they apply them. These choices may have implications on the user’s ocular comfort, ocular health and their contact lens-wearing experience. The purpose of this article is to provide eye care practitioners with information to offer their patients on the implications of using different cosmetic products.
Effects on the ocular surface
Eye cosmetics are applied in close proximity to the ocular surface. While eye shadow and mascara are applied to the peri-ocular skin and eyelashes, respectively, eyeliner is often applied millimetres away from the lid margins or even directly on the lid margin. Eyeliner is a popular product that is available in a pencil, gel or liquid form, used to accentuate and shape the appearance of the eyes.
Particles of cosmetic products applied so near to the eye are often seen suspended in the tear film or bound to the surface of contact lenses during routine anterior eye examination (see Figure 1: Eye cosmetics bound to the surface of a contact lens and suspended in the tear film. Image courtesy of Jalaiah Varikooty and Doerte Luensmann).4 Poor manual dexterity, an inferior application technique or eye rubbing all result in potential routes of entry for these products to mix with the tear film. Even substances applied to peri-ocular skin demonstrate slow and eventual migration into the tear film.5,6 Eyeliner that is applied to the inner lid margin can contaminate the tear film within five minutes of application and can still be observed up to two hours later. Eyeliner intentionally applied anterior to the lash line also contaminates the tear film; however, the quantity of contaminating particles is 50% less than when eyeliner is applied along the inner lid margin.6 Additionally, fine nylon fibres that are added to some ‘lash-lengthening’ mascara types can also enter the eye, as they become loose and fall from the lashes during the course of the day (see Figure 2: Fine fibres used in lengthening mascara formulations settling on the inner lid margin. image courtesy of Brian Tompkins). Patients with sensitive eyes should consider avoiding these mascaras to reduce the likelihood of any ocular irritation.
The immediate contamination of the tear film with eye cosmetics can disrupt tear film stability and subsequently reduce ocular comfort.7-9 A much less recognised cause of tear instability can originate from the removal of eye cosmetics. Removal products are applied to the skin with closed eyes. However, one study has demonstrated that when a cotton wool swab soaked with 4ml of cosmetic remover was used to wipe over closed eyelids, up to 7μl of cosmetic remover was still found to enter and contaminate the tear film.9 Cosmetic removers can destabilise the tear film and cause increased tear evaporation, with oil-based cleansers showing the greatest negative effect on tear stability.10 This is a particularly relevant point in the context of consumers choosing ‘long-lasting’ eye cosmetic products, which require the use of oil based cleansers to remove them effectively.
Cosmetic products and the meibomian glands
Eyeliner is one of the few eye cosmetic products to be intentionally applied along the inner lid margin, at the mucocutaneous junction. To date, only one pilot study has examined the potential effects on meibum after such methods of use. Hunter et al examined the melting point of meibum collected from study participants who used pencil or liquid eyeliner.11 The research team found that the melting point of meibum collected from those using these products was increased by 4°C. This altered melting point could affect the delivery of meibum into the tear film, thus altering tear stability and evaporation. However, no research has shown whether repeated use of eyeliner clogs up the meibomian glands.
There is some compelling evidence to support the notion that anti-ageing eye creams may lead to meibomian gland dysfunction. Retinoic acid (and its derivative, retinoid) is a common ingredient used in anti-ageing skin care products and some anti-acne products. In animal models, these ingredients cause thickening and keratinisation of meibomian gland ducts, degeneration and necrosis of meibomian gland acinar cells, peri-acinar fibrosis, and decreased lipid content of meibomian tissue.12 Although these effects have yet to be found in human users, practitioners should be aware of the unintended ocular physiological implications these products can have, considering the prevalence of dry eye associated with increased age, and the growing popularity of anti-ageing cosmetics.
Provocative instillation of eye cosmetic products has been shown to increase discomfort and irritation.9 One study examining the responses of 1360 people found that cosmetic users report greater levels of discomfort on days where they are wearing eye makeup compared to days when not wearing eye make-up.
However, dry eye symptomology determined using the OSDI questionnaire did not significantly differ from those who did not use eye make-up.8 A study by Guillon and Maissa also found that reports of sensitivity to eye make-up were associated with increased prevalence of dry eye symptoms in both symptomatic contact lens wearers and non-wearers.13
Cosmetic products manufactured and available for sale in the European Union are rigorously tested in order to conform to a set of standards outlined by the Cosmetics Directive; this ensures consumer confidence and safety in the products available.
Under the European Union’s Cosmetics Directive (1223/2009), manufactured cosmetic products must not cause harm to human health, and specific analytical methods are laid down for the testing of cosmetic products. Claims are occasionally made that products are ‘ophthalmologist tested/approved.’ These terms refer to the involvement of an ophthalmologist during the safety testing of the product. However, no standardised tests exist for these claims to used.14 Some ingredients used in out-dated cosmetic formulations are established to be harmful to human health and are no longer used. Some modern day ingredients may cause undesirable side effects, which will be discussed.
Kohl, a product similar to eyeliner, is one of the oldest eye cosmetics applied around the eyelid margins, and its use dates back to the early Bronze Age (c. 4000–1500 BC).1 Other terms used to describe the same product include surma (in Punjabi and Urdu), and al-kahal or kajal (in Hindu).15 A number of African, Middle Eastern and South Asian communities still use kohl, considering the eyes to be ‘vulnerable organs’ and believing that kohl performs a protective spiritual function against evil spirits.1,16 This type of kohl is illegal to import and sell in the United States as it contains ingredients no longer permitted in Western cosmetics, such as galena, sulphur, antimony, carb, iron and chromium.17 These ingredients are toxic and the use of traditional kohl has been associated with blood poisoning in babies due to high levels of lead.15,18
Preservatives are commonplace in cosmetic products and perform a fundamental role in maintaining safety and stability.19 Microbes require water to sustain their proliferation, which means that products with high water content, such as mascara, require more preservative ingredients than products with low water content such as eye shadow. Although preservatives improve the life span of a cosmetic product, some preserving ingredients are one of the most common causes of skin sensitivities and localised irritation.20 Older formulations of eye cosmetic products used preservatives such as benzalkonium chloride, thiomersal and chlorhexidine, which can cause tear instability.7 However, they are rarely used in any modern day cosmetic formulations.21 A list of commonly used preservatives is detailed in Table 1 (Table 1: Preservative permissible in the United States, European Union and Japan)22. To date, no studies have examined the effects of other preservatives on the tear film and ocular surface.
Bacterial contamination over the lifetime of a product is inevitable. Commensal bacteria typically found around the ocular adnexa include species of Haemophilus, Staphylococcus, Corynebacterium, Pneumococcus and Streptococcus. Although these bacteria are not harmful, bacteria can readily contaminate and multiply within the cosmetic product itself, leading to eye infections if used.23 One study found bacteria in 30% of mascaras tested after three months of use.23 In a separate study, 79% of used mascaras tested positive for Staphylococcus aureus and 13% were contaminated by Pseudomonas aeruginosa.24 The amount of bacteria within a product is related to the amount of use, the age of the product and the number of users, for example, where cosmetics are shared between users, or perhaps if the product is a ‘tester’ at a cosmetic counter.25,26
Preservatives only slow the proliferation of bacteria within the product. Over time, the efficacy of preservatives is reduced and products need to be replaced.27 A recent study conducted in a student population found that 98% of participants surveyed admitted to using cosmetic products beyond their expiration date, with mascara being the product most frequently used beyond its suggested replacement schedule.24 In this study, adverse reactions attributed to using expired cosmetic products included tearing, redness, itchiness and irritation.
European cosmetic labelling guidelines state that all cosmetic products must indicate for the ‘period after opening’ – the time limit within which the product must be used after opening, provided it has been stored in ‘normal’ conditions. Products are labelled with a symbol showing a jar with an open lid, indicating the number of months the product remains usable after opening. An alternative symbol used to convey the same message is an egg timer with the best before end date (see Figure 3: Egg timer and open jar symbols used to indicate the best before end and period after opening dates (6M=6 months)). It may be helpful to point this out to patients who present with symptoms suggesting expired cosmetics may be the cause.
Regular replacement of cosmetic products which are applied in close proximity to the eye and have a high water content, for example, liquid mascaras or eyeliner, is strongly advised.23-25,28 Patients should also be advised to avoid adding water to add longevity to these cosmetics as this significantly increases the risk of contaminating the products with environmental bacteria.
For products such as pencil eyeliner, sharpening of the tip of the pencil each time prior to application, thereby exposing uncontaminated product is recommended to minimise the likelihood of bacterial eye infections. Cosmetic products should not be shared with other users to limit the spoliation of the product and potential risk of spreading bacterial infections.29
Patients and practitioners should also be mindful of the method of removing topical creams, pastes and lotions from its original packaging.
While the manual/digital application of eye creams (with one’s fingertip) offers convenience, this method also introduces a further risk of bacterial contamination into the product. Many cosmetic products are supplied with an application tool to minimise this risk. However, these applicators also need to be cleaned and replaced on a regular basis to prevent the transfer of sebum, dead skin cells and waste matter back into the product.
Demodex mites, associated with acne rosacea, are commensal and their presence is known to cause Demodex-related blepharitis. Of the two types of mites attributed to blepharitis, it is Demodex brevis that thrive in oil-rich environments, and are commonly found in the sebaceous glands of Zeis and meibomian glands. If eye care practitioners are managing a patient with Demodex-related blepharitis, it is essential to eliminate the mite infestation before resuming cosmetic use. Any applicator sponges and brushes that readily accumulate sebum should be replaced often as part of managing this condition.30 Furthermore, eye care practitioners should remind all patients that they should refrain from using eye cosmetics during an eye infection, and that potentially contaminated eye cosmetic products need to be replaced after the infection is resolved.
Pharmaceuticals used in lash-enhancing products
Eye care practitioners should also be aware that pharmaceutical agents might feature as ingredients in cosmetics. One of the common side effects of prostaglandin analogues, typically used in the management of glaucoma is darker, thicker and longer eyelashes. In December 2008, Latisse (Allergan) 0.03% bimatoprost ophthalmic solution was approved by the US Food and Drug Administration (FDA) to be applied cutaneously daily along the lash line, for eyelash hypotrichosis.31 Although shown to be safe and effective,32 the incidence of conjunctival and eyelid hyperaemia was significantly greater in subjects using 0.03% bimatoprost than among subjects randomised to a vehicle-control.32,33 Additionally, the incidence of skin hyperpigmentation is increased with its usage which may be an undesirable cosmetic side effect.34
Cosmetics and the contact lens wearing patient
Using eye cosmetics simultaneously with contact lenses may also cause symptoms of dryness and discomfort.13,35,36 However, clinical studies to support this hypothesis are few. Cosmetic products are already known to have a propensity to bind to the surface of contact lenses which may not be readily removed by rubbing and rinsing with multipurpose solutions.4 Irreversible lens deformation and reduced optical clarity of silicone hydrogel lenses can be caused by cosmetics such as mascara and eye make-up removers.4,37
An in vitro study by Luensmann et al identified changes in lens diameter and sagittal depth in a range of frequent replacement silicone hydrogel contact lenses after contamination with make-up removers and waterproof mascaras.37 For some of the lens types studied, these conformational changes exceeded the International Organization for Standardization (ISO) acceptable tolerances of the lenses’ physical parameters to ensure proper functioning. Changes in physical dimensions could affect the fit of these lenses, which could be clinically relevant for those used on a monthly replacement modality. A separate study also found that cleansing oils caused silicone hydrogel lenses without plasma surface treatments to swell and deform; lenses which did receive a plasma treatment tended to resist lipid deposition and avoid such conformational changes.4
For regular users of eye cosmetics, practitioners should consider refitting these patients into a daily disposable contact lens to ensure optimum vision and comfort during the lens wearing experience. Practitioners should also remind patients that the order in which they apply their cosmetics and contact lens is important in minimising any manual transfer of cosmetic products to their lenses. Patients should be instructed to insert their contact lenses before applying eye cosmetics and to keep products such as eyeliner away from the lid margin to limit the amount of lens spoliation. Patients should be encouraged to remove their eye cosmetic products after each use and reminded to remove their lenses with clean hands before removing their eye cosmetics. Maintenance of good lid hygiene is associated with increased ocular comfort in patients with symptoms of dry eye.38
The global practice of eye cosmetic use is unlikely to change. Patient education is key and the eye care practitioner can play an active role in advising methods of usage and replacement of products. Cosmetic usage should be taken into consideration when managing the contact lens wearer and the dry eye patient.
About the author
Dr Alison Ng is a post-doctoral fellow at the Centre for Contact Lens Research, University of Waterloo, Canada. Her research interests focus on the interaction of the anterior eye and ocular surface in response to the environment and external stimuli, including contact lenses and cosmetic products.
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