Smart choices and healthy hygiene: beauty guidance for patients with ocular surface disease and irritation

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.

By Cecelia Koetting, OD, FAAO, DipABO

Eye makeup is the most common choice for those who wear makeup—about half wear mascara, and roughly 1 in 3 wear eyeliner and eyeshadow.¹ People wear makeup because they like it; it makes them happy and confident, and it becomes part of their identity.

As an ocular surface disease (OSD) specialist, I see how eye makeup and other beauty practices exacerbate OSD, including dry eye disease (DED), and irritate. Many patients tell me they had to stop wearing makeup, and they hate it. I want to help them wear makeup that is healthy, looks good, and makes sense for their situation. As we manage OSD and DED, our job is to ensure they choose the right eye makeup and follow hygienic practices for removing it.

Worst Offenders and Better Choices

Not all makeup is bad—it’s more about what ingredients products contain and how they are used. I ask my patients about the makeup and techniques they’re using and, if necessary, explain why those choices are problematic. Here’s a quick overview:

• Mascara: Non-waterproof mascara is best because it’s easier to remove thoroughly, leading to less makeup buildup and potential bacteria. If patients ask for specific brands, I recommend Eyes Are the Story, Twenty/Twenty Beauty, or Thrive Cosmetics. Patients should avoid lengthening and thickening mascaras, which contain filaments that can get into the eye and embed themselves in the cornea and conjunctiva. Mascara should be thrown away every 3 months to limit bacteria and Demodex buildup in the tube.
• Eyeliner: For healthy meibomian gland function, it’s best to avoid the “tightlining” trend where the liner is placed on the waterline directly over the meibomian glands. Many of the recommended mascara brands also make eyeliner. Tattoo eyeliner is not a great option because it could permanently damage the underlying meibomian glands.
• Eyeshadow: Cream eyeshadows that stay put are best. Powders can migrate into the tear film and cause irritation, which could be an issue for sensitive DED patients. Shimmer and glitter in some shadows can get into the tear film, potentially embedding into or scratching the ocular surface.
• Eyelash serums and tinting: Many over the counter and prescription eyelash serums contain prostaglandin analogs (PGA), listed or unlisted. PGAs can lead to side effects such as permanent pigment changes, periorbital fat atrophy, increased hyperemia, and meibomian gland dysfunction. There are eyelash serums that foster healthy hair follicles to help promote growth (Bausch + Lomb Lumify, Eye Illuminations Lash & Brow Serum, and Twenty/Twenty Beauty Get Growing). Another concerning trend is eyelash tinting and perming. The same chemicals used in hair treatments are used on eyelashes by an aesthetician or with at-home kits. I strongly recommend against patients utilizing these options.

How to Get It All Off

Hygienic makeup practices start with what patients put on their eyes and end with how they take it off. Every patient tells me they remove their eye makeup, but when I ask how they remove it, I get a fun assortment of answers: baby oil, Vaseline, cold cream, water, bar soap—all products that can be problematic for their eyes. Even patients who use makeup remover usually don’t use one that’s developed specifically for the eyes, so preservatives and other chemicals can cause irritation.

The problem is that no one teaches us how to clean our eyes the way they teach us to brush and floss our teeth. We can’t assume any patient knows how to clean their eyes, so education starts with the basics. I emphasize the importance of removing all eye makeup before bed every night and walk them through the process:

1. Use a good eye-safe makeup remover every night. I recommend micellar water products (Thea iVIZIA Micellar Eyelid Cleanser, Bausch + Lomb Lumify, Illuminations Cleansing Water, or Scope Eyecare’s Optase Life Makeup Remover).
2. Next, clean the lashes and around the eyes using an eyelid cleanser to control bacteria (Zocular ZocuFoam Eyelid Cleanser or Thea iVIZIA Eyelid Cleansing Gel). Put a little bit of the product in a clean hand, rub it into the eyelashes, let it sit for 15 seconds, and then rinse completely.
3. Finish with a good hypochlorous acid spray (Optase Protect, Scope Eyecare) to help control bacteria growth and balance the skin’s pH.

Good eye hygiene helps improve bacterial load, promote healthy meibomian glands, reduce Demodex, and keep abrasive substances off the ocular surface, all of which are especially important for patients with OSD or DED. For many patients—especially young, healthy people whose eyes have a great capacity to rebound—I find that good hygiene combined with a conservative approach to DED therapy is often effective.

I start patients off with a high-quality, preservative-free artificial tear (Thea iVIZIA or Scope Eyecare’s Optase MGD) as needed during the day, a daily supplement (Bausch + Lomb’s Blink Nutritear and either HydroEye from ScienceBased Health or PRN De3), and the all-important eyelid hygiene, followed by nightly use of a heat mask with eyelid massage.

Handouts Are a Must

It is difficult for patients to remember these explanations, how-to’s, and product recommendations. Utilizing a handout that explains everything step by step gives them a reminder and sets them up for success. My handout lists some recommended products, as well as ingredients to avoid. Many people don’t realize that the ingredients in makeup and other beauty products are not well regulated and can be bad for their eyes—even products marked “hypoallergenic” or “all-natural.” Once I explain, they’re happy to get some guidance.

If patients are uncertain about an ingredient, they can check the Environmental Working Group’s website (www.ewg.org), which rates ingredients’ safety and explains their risks. I also tell my patients to send me a picture of the product if they’re not sure, and I’ll let them know if it’s a safe choice.

Case: 30-Year-Old with Poor Makeup Hygiene and MGD

A 30-year-old woman referred to me for DED treatment was frustrated with her inability to wear contact lenses comfortably all day. She told me her eyes felt dry all the time. Under the slit lamp, I found 1+ corneal superficial punctate keratitis (SPK), a TBUT of 4 seconds, makeup debris, and 1+ blepharitis in both eyes. I had to press hard to express very cloudy oil from her meibomian glands. When I asked the patient about traces of eye makeup on her lids, she said she last wore makeup 2 days ago.

I explained the patient’s diagnosis of meibomian gland dysfunction (MGD) and blepharitis, noting that to get the glands functioning properly, hygiene is very important. She had previously used a face wash product on her eyes to remove makeup. We went through how to use an eye makeup remover every night (Optase One Life, Scope Eyecare), followed by an eyelid cleanser (Zocular ZocuFoam Eyelid Cleanser) to control her overgrowth of bacteria. I explained that she needed a contact lens-compatible, preservative-free artificial tear (iVIZIA, Thea) when she wakes up and after taking contacts out at the end of the day to help moisturize and lubricate her dry eyes. Warm compresses and omega-3 supplements would improve the quality and consistency of the meibum. I also checked the patient’s makeup brands and gave her the handout with healthier choices.

When the patient returned 6 weeks later, her eyes looked better. The SPK was gone, and her meibum showed improvement. She could wear her contacts longer, and I expect that will continue to improve as she follows her regimen. The hygiene, artificial tears, and other therapies were having the intended effect, so we didn’t need to add a prescription medication at this time. Like many makeup wearers, a beauty routine with better choices, good hygiene habits, and conservative therapy was the key to healthier, more comfortable eyes.

Cecelia Koetting, OD, FAAO, DipABO, is an optometrist and clinical faculty at the University of Colorado School of Medicine in the Department of Ophthalmology. Disclosures: Alcon, Aldyera, Allergan, Avallino, Azura, Bausch + Lomb, BlinkJoy, Bruder, Claris Bio, Dompe, Eyevance/Santen, Glaukos, Harrow, Johnson & Johnson, Kala, Myze, Ocular Therapeutix, Orasis, Oyster Point/Viatris, RVL, SightSciences, Tarsus, Thea, Twenty/Twenty, Versea, Visus.

Reference

1. Orth T. How often — and why — American women wear makeup. YouGov. Published December 11, 2023. Accessed September 26, 2024. https://today.yougov.com/society/articles/48130-why-american-women-wear-makeup-poll