TFOS Lifestyle: Impact of cosmetics on the ocular surface

The impact of eyeliner usage on dry eye symptoms

The objective of this study was to investigate whether eyeliner use is associated with an increase in dry eye symptoms. A survey was conducted to collect data on cosmetic usage and Ocular Surface Disease Index (OSDI) scores from a diverse public sample. Additionally, eyecare professionals were queried regarding their practice of inquiring about cosmetic use during patient consultations. The survey included specific questions about eyeliner application and the calculation of OSDI scores, with a score of 13 or higher indicating the presence of dry eye symptoms. Individuals who reported using eyeliner had a significantly higher rate of OSDI scores above 13 compared to non-users (42.93% vs. 33.38%, p < 0.001). Notably, subjects who applied eyeliner to the lid margins exhibited an even more pronounced increase in high OSDI scores (48.17%, p < 0.001). Furthermore, a significant proportion of patients (23.37%) expressed reluctance to discontinue cosmetic use when advised in medical contexts, while only 48.19% of healthcare providers routinely inquired about cosmetic use during patient consultations. The usage of eyeliner is associated with higher OSDI scores, underscoring the need for both eyecare practitioners and eyeliner users to be more cognizant of the potential impact of eyeliner on the ocular surface.

Why ignore expiry dates on cosmetics? A qualitative study of perceived risk and its implications for cosmetics producers and regulators

Consumers often use cosmetics long after their expiry date, despite the health risk. This paper aims to understand why and to suggest policy changes that can promote safer practices in cosmetics use. This is the first study to investigate risk perception in relation to expired cosmetics. Thirty-three semistructured interviews with both cosmetics users and employees of cosmetics companies were conducted in the United Kingdom and China. Perceived risk theory was found to be a useful analytical lens. Eight risk factors emerged from the data, including two not previously identified. Combinations of risk were also found to be valuable in explaining consumer attitudes to cosmetic expiry dates, which suggests that perceived risk factors interact with each other to create an emergent perception of risk, requiring an integrated understanding. While physical, performance and self-brand connection risk can promote adherence to an expiry date, other risk factors such as financial and social risk can override such concerns, leading to the expiry date being ignored. Implications for suppliers' and regulators' policies and risk-communication strategies are identified that may help reduce the risks being taken by cosmetics users.

Perspectives of dry eye patients in the United Kingdom on risk factors and desired treatment outcomes

PURPOSE

Successful management of dry eye disease depends upon an effective two-way communication between eyecare practitioners and affected patients. However, there has been limited investigation into the perspectives of patients with dry eye disease in the United Kingdom regarding their risk factors and desired treatment outcomes.

METHODS

An online, self-administered, anonymous survey was distributed to patients based in the United Kingdom who have had a diagnosis of dry eye disease between November 2023 to March 2024. The survey consisted of four main sections including demographics, the 5-item Dry Eye Questionnaire (DEQ-5), and Likert scales rating the likelihood of various risk factors contributing to their dry eyes and the desired treatment outcomes in various components of signs and symptoms.

RESULTS

The survey was completed by 152 respondents (mean age 51.7 ± 16.7 years, 103 females). Respondents rated environmental conditions the highest in terms of likelihood of contributing to their dry eye disease [median (interquartile range): 7.5 (5-10)], followed by digital device use [7 (4-9)] and poor sleep quality [4 (1-7)]. In terms of desired treatment outcomes, symptom frequency and severity as well as tear stability were ranked the highest in importance [10 (8-10)].

CONCLUSIONS

This survey demonstrated the perceptions of dry eye patients in the United Kingdom regarding lifestyle or modifiable risk factors contributing to their dry eye disease, as well as the most important treatment outcomes of these patients. These aspects should be considered by clinicians in the management of dry eye disease, as well as researchers particularly when designing studies which investigate treatment effects of current and novel dry eye interventions.

Ocular surface side effects of botulinum toxin type A injections in the treatment of lateral canthal wrinkles (Crow's Feet)

PURPOSE

This study investigates the impact of Botulinum Toxin Type A (BoNT-A) injections for lateral canthal wrinkles on the ocular surface.

METHODS

A total of 30 patients (30 eyes) who received BoNT-A injections were followed over a three-month period. Evaluations included tear meniscus height (TMH), strip meniscometry test, fluorescein tear film break-up time (FTBUT), corneal staining score, meibomian gland orifice and meibum quality score. Observations were recorded at baseline, one week, one month, and three months post-injection.

RESULTS

Upper and total eyelid meiboscore, meibomian gland orifice obstruction, and meibum quality score peaked at three months post-injection, while FTBUT was shortest during the same period, with significant differences observed across time points (P < 0.05). Post-hoc analysis indicated a significant reduction in FTBUT between baseline and three months (P = 0.048). Corneal staining scores were highest at one week, with significant differences across time points (P < 0.001); post-hoc analysis revealed a significant difference between one week and three months (P = 0.037). No significant changes were found in TMH or strip meniscometry test score (P = 0.374, P = 0.732).

CONCLUSIONS

BoNT-A injections may temporarily compromise ocular surface stability by decreasing tear film stability, disrupting meibomian gland function, and causing corneal epithelial disruption.

Implications of Long-Term Double Eyelid Tape Use

BACKGROUNDS

The widespread adoption of double eyelid tapes (DET) to achieve the desired double eyelid aesthetic has prompted investigations into their long-term effects. Given the delicate and complex anatomy of the eyelid, concerns have emerged about the impact of DETs on eyelid structure and the outcomes of subsequent surgical procedures.

METHODS

A cohort of 267 outpatients from our department was recruited between January 2022 and January 2024 to participate in a survey assessing the usage of double eyelid tape (DET). Eyelid laxity was subsequently tested in all outpatients using the Vertical Lid Pull and Parallel Lid Pull methods. Among all participants, 33 underwent double eyelid surgery, with 22 having a history of excessive DET usage and 11 with no DET usage. Post-operative outcomes, including operation duration, satisfaction levels, and complications were recorded. Additionally excised eyelid skin tissues during surgery underwent Masson's staining and EVG staining to analyze collagen and elastic fibers.

RESULTS

Among surveyed outpatients (mean age: 23.79 ± 3.71 years, 99.63% female, mean BMI: 21.56 ± 1.75 kg/m2), 56.55% had oculopathy with ametropia being predominant (53.93%). Hooded eyelids were the most prevalent congenital condition (62.54%). Nearly half (49.44%) used Double Eyelid Tapes (DET) for 1-2 years, with 70.04% experiencing discomfort and 70.79% reporting permanent eyelid shape change. Lid pull measurements showed no significant difference in vertical pulls between DET users and non-users, but parallel pulls varied significantly (p<0.05). Complications like asymmetry, numbness, and hypertrophic scars were exclusive to DET users. Physician evaluations favored non-DET users significantly (p<0.05). Histological analysis revealed an interesting finding that individuals using DET have higher collagen levels and notable changes in skin structure when compared to non-users.

CONCLUSIONS

Prolonged use of double eyelid tape (DET) may result in eyelid laxity, impacting ocular health and complicating blepharoplasty procedures.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of the Safety and Tolerability of Lumify Eye Illuminations Cosmetic Products

Purpose

Cosmetic products applied to the periocular area can cause skin sensitivity reactions, and manufacturers routinely test the safety and tolerability of products in development. This research was sponsored by Bausch + Lomb to evaluate three Lumify Eye Illuminations products: a lash and brow serum, a hydra-gel eye cream, and a micellar water eye makeup remover.

Methods

A cumulative irritation test (CIT) study and a repeated insult patch test (RIPT) study enrolled adult males or females with no known sensitivities to cosmetic products. Three clinical safety studies enrolled adult females with self-reported characteristics targeted by each product, which was applied in a manner consistent with expected use for 8 or 12 weeks.

Results

In CIT (n=34) and RIPT (n=201) studies, faint/minimal erythema reactions were observed in 0% to 2.9% of participants; there were no moderate or severe reactions. No safety signals were observed in participants who completed clinical safety studies for lash and brow serum (n=66 enrolled, n=55 completed [83%]), eye cream (n=61 enrolled, n=52 completed [85%]), or eye makeup remover (n=80 enrolled, n=68 completed [85%]). No clinically relevant changes in visual acuity or ophthalmologic slit-lamp examination findings were noted. No participants reported ocular sensations of burning/stinging, foreign-body sensation, or soreness. At the final clinical safety study assessment, mild cutaneous erythema (as graded by the investigator) was reported for one participant (eye cream study); no other prespecified signs of cutaneous irritation (eg, edema, dryness) were observed. A treatment-related adverse event that led to study discontinuation was experienced by one participant in the eye makeup remover study (bilateral periorbital swelling).

Conclusion

Findings from rigorously conducted irritation testing and clinical safety studies indicated that these products were safe and well tolerated. Increased availability of data regarding ocular and cutaneous safety of cosmetic products can inform consumer decision-making and eye care provider recommendations.

Epidemiology and Risk Factors of Dry Eye Disease: Considerations for Clinical Management

Dry eye disease is a multifactorial condition characterised by tear film instability, hyperosmolarity and ocular surface inflammation. Understanding the epidemiology of dry eye disease and recognising both modifiable and non-modifiable risk factors can assist eye care practitioners in assessing, treating, and managing patients with the condition. This review considers current knowledge surrounding its incidence and prevalence, as well as associated demographic, systemic, ocular, and iatrogenic, and lifestyle-related modifiable risk factors. Population-based prevalence estimates vary according to the diagnostic criteria used to define dry eye disease, as well as severity and demographic characteristics of the population. Considering recent data and variable population demographics, conservative prevalence estimates suggest that 10-20% of the population over 40 years of age report moderate to severe symptoms and/or seek treatment for dry eye disease. Individuals with specific non-modifiable demographic risk factors may be at increased risk of developing dry eye disease. Advanced age, female sex and East Asian ethnicity have been identified as key non-modifiable demographic features predisposing individuals to dry eye disease. Systemic conditions that have been associated with an increased risk of dry eye disease include migraine, Sjögren syndrome, connective tissue disorders, mental health disorders, diabetes mellitus and androgen deficiency. Medications that may contribute to this risk include antidepressants, antihistamines, and hormone replacement therapy. Ocular and iatrogenic risk factors of dry eye disease include blepharitis, Demodex infestation, ocular surgery, blink completeness, contact lens wear, and topical ophthalmic medications. A range of modifiable lifestyle factors that can increase the risk of dry eye disease have also been identified, including low humidity environments, digital screen use, quality of sleep, diet, and eye cosmetic wear. Dry eye is a common disease affecting millions globally. Increasing knowledge regarding its associated risk factors can better prepare the eye care practitioner to successfully manage patients with this ocular surface disease.

Beauty versus Health-How Eyelash Extensions May Affect Dry Eye Disease?

Background: Eyelash extensions (EEs) are among the most popular cosmetic procedures today. There is no prospective study demonstrating how this procedure affects the ocular surface and eye dryness in particular. The goal of this study is to evaluate the effect of EEs removal on dry eye symptoms and signs. Materials and Methods: The subjects were prospectively recruited from routine clinical examinations for dry eye complaints. Only subjects with an OSDI score above 31 were included in the study. The subjects also planned to have the EEs removed and agreed to abstain from makeup use and new cosmetic procedures for 4 weeks. The presence of dry eye was evaluated by an OSDI questionnaire, and objectively by tear breakup time (TBUT), staining (Oxford scale) and blinking intervals. All tests for dry eye were performed at baseline and 4 weeks after EEs removal. Results: The mean age of our patients, all female, was 28 years. The size and type of EEs was diverse. The decision process was mainly based on appearance and models. None of the subjects had any health conditions. The mean result from the score from the OSDI questionnaire at the baseline was 33.4 and improved to 26.7 points 4 weeks after EEs removal. Objectively, the mean TBUT increased from 11.25 to 13.96 s. For the same period, the blinks increased by two per minute, and the staining was reduced by 1.0 grade. Conclusions: Removal of EEs improves the symptoms and the objective signs of dry eye. The most popular beauty procedure regarding eyelashes might not be innocuous to eye health.

The effects of eyelash extensions on the ocular surface

PURPOSE

To investigate the effects of eyelash extensions on the ocular surface.

METHODS

This prospective study included 32 participants with eyelash extensions in both eyes. Symptoms and clinical parameters such as conjunctival vascular density, tear meniscus height (TMH), noninvasive tear break-up time, bulbar redness, meibography, lipid layer thickness, and corneal staining were assessed in the right eyes. These measurements were taken at baseline and 1 h, 1 day, 1 week, and 1 month after eyelash extensions were applied.

RESULTS

At 1 h after eyelash extensions, ocular symptoms were reported by 27 participants (84.44 %), the most common being foreign body sensation (59.38 %). However, the Ocular Surface Disease Index scores were not statistically different between baseline, 1 week, and 1 month after eyelash extension (P > 0.05). TMH increased significantly at 1 h after eyelash extensions, from 0.27 ± 0.08 mm (baseline) to 0.29 ± 0.07 mm (P = 0.02). Subsequently, TMH decreased and was the lowest at 1 week at 0.24 ± 0.08 mm. First tear break-up time and average tear break-up time decreased to the lowest at 1 week after eyelash extension, with 8.36 ± 4.6 s and 10.71 ± 4.99 s, respectively, both of which were statistically different from baseline (P < 0.05). Corneal staining score was highest at 1 h after eyelash extensions at 0.78 ± 1.34. However, there were no significant differences in the conjunctival vascular density, bulbar redness, meiboscore, or lipid layer thickness.

CONCLUSION

This study demonstrates that eyelash extensions can lead to an imbalance in ocular surface homeostasis, resulting in corneal epithelial defects and short-term decreased tear film stability.

New Korean Guidelines for the Diagnosis and Management of Dry Eye Disease

New Korean guidelines for the diagnosis and management of dry eye disease were developed based on literature reviews by the Korean Dry Eye Guideline Establishment Committee, a previous dry eye guideline by Korean Corneal Disease Study Group, a survey of Korean Dry Eye Society (KDES) members, and KDES consensus meetings. The new definition of dry eye was also proposed by KDES regular members. The new definition by the regular members of the KDES is as follows: "Dry eye is a disease of the ocular surface characterized by tear film abnormalities and ocular symptoms." The combination of ocular symptoms and an unstable tear film (tear breakup time <7 seconds) was considered as essential components for the diagnosis of dry eye. Schirmer test and ocular surface staining were considered adjunctive diagnostic criteria. The treatment guidelines consisted of a simplified stepwise approach according to aqueous deficiency dominant, evaporation dominant, and altered tear distribution subtypes. New Korean guidelines can be used as a simple, valid, and accessible tool for the diagnosis and management of dry eye disease in clinical practice.

A novel rice hull - microalgal biorefinery for the production of natural phenolic compounds comprising of rice hull acid pretreatment and a two-stage Botryococcus braunii cultivation process

Recently, the rising demand of the industry for natural phenolic antioxidant compounds has turned to the study of microalgae as potential sources. Yet, more economic substrates for microalgal cultivation are sought to lower production costs. To this end, the present work deals with the utilization of rice hull hydrolysate (RHH) as substrate for microalgae Botryococcus braunii through a novel two-stage cultivation system. Initially, RHH was optimized to maximize the contained nutrients while minimizing its inhibitors content. The optimum point was reached under 121 °C, 60 min, 2% (v/v) H2SO4, 30% (w/v) loading. Next, B. braunii was successfully grown first heterotrophically in RHH (25%, v/v), obtaining high biomass production (6.67 g L-1) and then autotrophically to enhance phenolics accumulation. At the end, a high phenolic content of 7.44 ± 0.60 mg Gallic Acid Equivalents g-1 DW was achieved from the produced biomass, thus highlighting the potential of this novel biotechnological method.

Cysteamine hydrochloride affects ocular development and triggers associated inflammation in zebrafish

The increasing use of cosmetics has raised widespread concerns regarding their ingredients. Cysteamine hydrochloride (CSH) is a newly identified allergenic component in cosmetics, and therefore its potential toxicity needs further elucidation. Here, we investigated the in vivo toxicity of CSH during ocular development utilizing a zebrafish model. CSH exposure was linked to smaller eyes, increased vasculature of the fundus and decreased vessel diameter in zebrafish larvae. Moreover, CSH exposure accelerated the process of vascular sprouting and enhanced the proliferation of ocular vascular endothelial cells. Diminished behavior in response to visual stimuli and ocular structural damage in zebrafish larvae after CSH treatment were confirmed by analysis of the photo-visual motor response and pathological examination, respectively. Through transcriptional assays, transgenic fluorescence photography and molecular docking analysis, we determined that CSH inhibited Notch receptor transcription, leading to an aberrant proliferation of ocular vascular endothelial cells mediated by Vegf signaling activation. This process disrupted ocular homeostasis, and induced an inflammatory response with neutrophil accumulation, in addition to the generation of high levels of reactive oxygen species, which in turn promoted the occurrence of apoptotic cells in the eye and ultimately impaired ocular structure and visual function during zebrafish development.

TFOS Lifestyle Report Executive Summary: A Lifestyle Epidemic - Ocular Surface Disease

The Tear Film & Ocular Surface Society (TFOS) Workshop entitled 'A Lifestyle Epidemic: Ocular Surface Disease' was a global initiative undertaken to establish the direct and indirect impacts of everyday lifestyle choices and challenges on ocular surface health. This article presents an executive summary of the evidence-based conclusions and recommendations of the 10-part TFOS Lifestyle Workshop report. Lifestyle factors described within the report include contact lenses, cosmetics, digital environment, elective medications and procedures, environmental conditions, lifestyle challenges, nutrition, and societal challenges. For each topic area, the current literature was summarized and appraised in a narrative-style review and the answer to a key topic-specific question was sought using systematic review methodology. The TFOS Lifestyle Workshop report was published in its entirety in the April 2023 and July 2023 issues of The Ocular Surface journal. Links to downloadable versions of the document and supplementary material, including report translations, are available on the TFOS website: http://www.TearFilm.org.

Impact of Exposomes on Ocular Surface Diseases

Ocular surface diseases (OSDs) are significant causes of ocular morbidity, and are often associated with chronic inflammation, redness, irritation, discomfort, and pain. In severe OSDs, loss of vision can result from ocular surface failure, characterised by limbal stem cell deficiencies, corneal vascularisation, corneal opacification, and surface keratinisation. External and internal exposomes are measures of environmental factors that individuals are exposed to, and have been increasingly studied for their impact on ocular surface diseases. External exposomes consist of external environmental factors such as dust, pollution, and stress; internal exposomes consist of the surface microbiome, gut microflora, and oxidative stress. Concerning internal exposomes, alterations in the commensal ocular surface microbiome of patients with OSDs are increasingly reported due to advancements in metagenomics using next-generation sequencing. Changes in the microbiome may be a consequence of the underlying disease processes or may have a role in the pathogenesis of OSDs. Understanding the changes in the ocular surface microbiome and the impact of various other exposomes may also help to establish the causative factors underlying ocular surface inflammation and scarring, the hallmarks of OSDs. This review provides a summary of the current evidence on exposomes in various OSDs.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

TFOS Lifestyle: Impact of nutrition on the ocular surface

Nutrients, required by human bodies to perform life-sustaining functions, are obtained from the diet. They are broadly classified into macronutrients (carbohydrates, lipids, and proteins), micronutrients (vitamins and minerals) and water. All nutrients serve as a source of energy, provide structural support to the body and/or regulate the chemical processes of the body. Food and drinks also consist of non-nutrients that may be beneficial (e.g., antioxidants) or harmful (e.g., dyes or preservatives added to processed foods) to the body and the ocular surface. There is also a complex interplay between systemic disorders and an individual's nutritional status. Changes in the gut microbiome may lead to alterations at the ocular surface. Poor nutrition may exacerbate select systemic conditions. Similarly, certain systemic conditions may affect the uptake, processing and distribution of nutrients by the body. These disorders may lead to deficiencies in micro- and macro-nutrients that are important in maintaining ocular surface health. Medications used to treat these conditions may also cause ocular surface changes. The prevalence of nutrition-related chronic diseases is climbing worldwide. This report sought to review the evidence supporting the impact of nutrition on the ocular surface, either directly or as a consequence of the chronic diseases that result. To address a key question, a systematic review investigated the effects of intentional food restriction on ocular surface health; of the 25 included studies, most investigated Ramadan fasting (56%), followed by bariatric surgery (16%), anorexia nervosa (16%), but none were judged to be of high quality, with no randomized-controlled trials.

TFOS Lifestyle: Impact of contact lenses on the ocular surface

Several lifestyle choices made by contact lens wearers can have adverse consequences on ocular health. These include being non-adherent to contact lens care, sleeping in lenses, ill-advised purchasing options, not seeing an eyecare professional for regular aftercare visits, wearing lenses when feeling unwell, wearing lenses too soon after various forms of ophthalmic surgery, and wearing lenses when engaged in risky behaviors (e.g., when using tobacco, alcohol or recreational drugs). Those with a pre-existing compromised ocular surface may find that contact lens wear exacerbates ocular disease morbidity. Conversely, contact lenses may have various therapeutic benefits. The coronavirus disease-2019 (COVID-19) pandemic impinged upon the lifestyle of contact lens wearers, introducing challenges such as mask-associated dry eye, contact lens discomfort with increased use of digital devices, inadvertent exposure to hand sanitizers, and reduced use of lenses. Wearing contact lenses in challenging environments, such as in the presence of dust and noxious chemicals, or where there is the possibility of ocular trauma (e.g., sport or working with tools) can be problematic, although in some instances lenses can be protective. Contact lenses can be worn for sport, theatre, at high altitude, driving at night, in the military and in space, and special considerations are required when prescribing in such situations to ensure successful outcomes. A systematic review and meta-analysis, incorporated within the review, identified that the influence of lifestyle factors on soft contact lens dropout remains poorly understood, and is an area in need of further research. Overall, this report investigated lifestyle-related choices made by clinicians and contact lens wearers and discovered that when appropriate lifestyle choices are made, contact lens wear can enhance the quality of life of wearers.

TFOS lifestyle: Impact of societal challenges on the ocular surface

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.