Sore and swollen eyes after false eyelash appointment

The question:

A lady comes in with sore eyes, red and swollen eyelids, mild photophobia and watering. She had some false lashes put on at a beauty salon yesterday. Two hours later, her eyelids became hot, tingly and itchy. Her daughter’s wedding is tomorrow and she’s desperate for some help. What can you do?’

OT’s panel says...

Kevin Wallace: I have seen a case like this recently and it is likely to be an allergic reaction – probably to the adhesive used. The most important thing with any allergy is to remove the allergen if possible, in this case that is obviously the lashes and their adhesive.

Although it isn’t clear at the moment that this is actually an eye problem it is clearly affecting the adnexa so is reasonable for an optometrist with appropriate experience to treat.

Once you remove the allergen the usual treatment of regular lubrication and a cool compress will give her some relief and reduce the signs in most cases. The added wrinkle in this case is the fact that the patient has a wedding tomorrow and will be clearly concerned about cosmesis.

I think it is very unlikely that her symptoms would resolve in time for the following day with any treatment but a short course of ‘non-penetrating steroid’ may improve the signs and symptoms.

There is probably also a difficult conversation to be had with the patient about whether she should wear any eye makeup tomorrow as well as the risk of a short course of steroids and whether they are necessary.

Ankur Trivedi: I would ask whether she had had false lashes before, either with the same or with no reaction. I would also ask whether patch testing was done prior to the treatment, to rule out any chance of reaction.

There is a strong likelihood that this is an allergic reaction to the lash glue, or to some other element that was used for the lash treatment.

In an ideal world, the first thing would be to remove the lashes and glue to remove the allergen or trigger. Given the context, I can imagine this would not be welcomed, so I would want to prescribe some steroids – ideally something that is non-penetrating, and available in a preservative-free version.

Ceri Smith-Jaynes: This is a real case from practice. The patient had had the eyelash extension treatment once before, with no adverse reaction.

Something in the glue has probably caused the reaction. It has been suggested that formaldehyde in lash extension glue can be emitted from the glue a few hours after application and can be volatile, depending on temperature and humidity. This is a potential cause of the reaction in the skin.

This patient is complaining of photophobia, so I’m going to need a good look at her cornea, with fluorescein, as there is likely to be keratoconjunctivitis too. The volatile compound can dissolve in the tear film and cause ocular surface damage. This patient had a small infiltrate on one cornea, along with bilateral inferior staining and bulbar and palpebral hyperaemia. There was a bit of yellowy discharge as well as glue residue on the lashes.

Kevin Wallace: It’s definitely important to examine the rest of the eye – particularly using fluorescein to assess the cornea. I always check what the patient can see before we start too – clearly reduced acuity is an important sign in any eye problem and a pinhole is very useful to differentiate ametropia from a pathological reason.

Ceri Smith-Jaynes: I think the most appropriate College Clinical Management Guideline to apply here is Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa). The condition is described as “chemical irritation of ocular and/or adnexal tissues by a topically applied drug, contact lens care product or cosmetic, or by environmental or occupational substances.”

Treatment in the guideline includes withdrawal of the offending medication or preservative and cold compress (symptomatic relief). Eyelash glue requires an oil to dissolve, so you’ll need an oil-based cleanser, eye make-up remover, olive oil, or Vaseline. I’d try warm water first, though. The lids are sore and inflamed, so I’d get a cool gel pack on as soon as the lashes are off.

I’d advise copious ocular lubricants, which will be soothing if you refrigerate them. I’d prefer to go preservative-free for any treatment in this case – dexamethasone or prednisolone steroid drops are available in unit dose and will help with inflammation.

I’d prefer to go preservative-free for any treatment in this case

The guidance also notes that antihistamines and mast cell stabilisers are not recommended for the treatment of conjunctivitis medicamentosa, because they are ineffective in controlling inflammation in type IV hypersensitivity reactions.
 
We’d like this to resolve quickly with the wedding tomorrow. It’s important to measure visual acuity. I don’t think I want to hit this lady with Goldmann tonometry if she’s struggling to open her eyes, but I’ll check IOPs in a few days, when she returns for follow-up. I’d like a baseline IOP reading because of the steroid treatment, although I don’t anticipate her needing the steroid for more than a week or so.

I also considered the College guideline for chemical trauma. My first thought was allergy, but is it actually a chemical burn? Although the reaction here is delayed, is that because the glue warmed up to skin temp and released volatile compounds which damaged the eye and dissolved into the tears, rather than a real hypersensitivity response? If cases like this present, should we be irrigating?

I do think this falls under the remit of IP optometrists, however, we must always bear in mind College of Optometrists guidance, that “you must recognise and work within the limits of your professional competence” and “if you observe a sign or symptom which you cannot manage within your competence, you must refer the patient to a practitioner with the appropriate qualifications and registration.”

In my area, anyone who phones their GP and uses the word ‘eye’ is signposted to CUES. These patients are presenting to us, and I think we need to help them. Even if the examination results in palliation and an onward referral to ophthalmology (or a more experienced IP optometrist), the referral will be more effectively triaged with a good quality letter detailing the findings.

Sometimes, I’ll phone for advice and the ophthalmologist will ask me to start a treatment, then they will follow up the next day. This is great service, from the patient’s point of view.

 

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