Paying the Price for Beauty

Kendall E. Donaldson, MD, MS and Cynthia Mathossian, MD

Society places such emphasis on appearance and maintenance of the youthful beauty that fades with age. Although cultures vary around the world, most of us struggle with age-related changes and are willing to spend both time and money for beautification, some times even at the cost of significant discomfort and disabling side effects. Over the past several years we have seen the emergence and increased popularity of a number of cosmetic options that may lead to ocular infection, inflammatory conditions and even permanent vision loss.

Procedures such as scleral tattoos, scleral whitening (with mitomycin C or white ink), and application of eye jewelry have led to both acute and chronic infection and inflammatory conditions including scleritis, episcleritis, avascular necrosis, and ocular surface disruption and disease. Scleral whitening procedures involve the injection of agents such as white tattoo ink beneath the conjunctiva and they are then distributed through digital pressure to achieve a homogenous white appearance to the conjunctiva. However, within the first few days, these procedures may be associated with increased tearing, photophobia, redness and foreign body sensation due to the inflammation associated with the these foreign substances in the subconjunctival space.¹

Additionally, eyelash extensions (false eyelashes) and embellishments have also increased in popularity while exposing patients to toxic formaldehyde-based adhesives (sometimes at impressively high levels) and creating a “wick” for entry and harboring of infectious organisms to enter the ocular surface.^2,3,4 Similar scenarios have been associated with the newer lash embellishments, decorative additions adorning the lashes to provide added “bling”, drawing attention to the eyes. Eyelash extensions have been documented to be associated with allergic blepharitis, keratoconjunctivitis, chemical keratitis, and conjunctival erosions.³ These foreign bodies can increase risk for intraocular surgery and should be removed in advance of surgery (when identified pre-operatively). Permanent eyeliner and eyelid tattooing have also become fashionable but can lead to initiation or exacerbation of chronic blepharitis or blepharoconjunctivitis as well as contributing to meibomian gland drop out. These procedures may lead to chronic lash loss (from chronic formaldehyde exposure) and long-term eyelid edema, in some cases.² The American Academy of Ophthalmology recommends that only certified aestheticians provide such services to ensure certain baseline training in an attempt to reduce potential risk.³

Figure 1: Eyelash Embellishments

Figure 2: Cosmetic Contact Lenses

Cosmetic contact lenses have long been a concern due to increased risk of infection from long-term wear (sleeping and partying in lenses) and inappropriate distribution and fitting (or lack of fitting) practices. In attempt to limit such situations, the American Academy of Ophthalmology released a statement against distribution of these lenses by non-ophthalmic providers in 2005. However the idea that these lenses are simply a component of a costume for an upcoming holiday or a complementary element of an outfit, challenges their acceptance as a medical device that may be associated with significant sight-threatening side-effects.

Living in a world with societal pressures to achieve and maintain youthful beauty for success have driven many (especially women) to pursue a variety of aesthetic options to achieve this goal. However, oftentimes these procedures are associated with significant risks unbeknownst to the patient. As eye care professionals, it is our role to educate patients about the risks of these procedures and direct them towards appropriate avenues for which they can more safely pursue their goals. When possible, we should consider a thorough ophthalmic exam and the use of ocular surface diagnostics such as tear osmolarity (TearLab), meibomography (LipiView, TearScience or Keratograph 5M, Oculus), and assessment of ocular surface inflammation (RPS, Inflammadry) to evaluate these patients prior to their procedure or when assessing treatment response thereafter. Education is key for these patients, as many of them pursue a variety of beauty interventions and repeat them frequently to maintain their goal of ephemeral beauty.

Reference(s):
References
1. Campion M, Campion RJ, Campion VM. Eye Whitening Using Subconjunctival Injections. Am J Cosmet Surg. December 2015. vol. 32 no. 4 254-257.
2. Amano Y, Sugimoto Y, Sugita M. Ocular disorders due to eyelash extentions. Cornea. 2012 Feb;31(2):121-5.
3. Avitzur O. Eyelash extensions can pose health risks. Consumer Reports. 2013 May. http://www.consumerreports.org/cro/2013/05/eyelash-extensions-can-pose-health-risks/index.htm.
4. Amador GJ, Mao W, DeMercurio P, Montero C, Clewis J, Alexeev A, Hu DL. Eyelashes divert airflow to protect the eye. J R Soc Interface. 2015 Apr 6;12(105).

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