Dry Eye Dx and Tx

Prescribe Lid Hygiene, Especially for Makeup Wearers

Dry Eye Dx and Tx

Prescribe Lid Hygiene, Especially for Makeup Wearers


I admit it, I really enjoy the allure of makeup. I am particularly interested, of course, in eye makeup. Mascara and eyeliner; creams and powders; pencils, gels, and kohls; minerals and pigments...all for application to the lids, lid margins, and lashes.

Current Eye Makeup Trends

Today’s cosmetics feature a host of activators, sealants, and specialty brushes to intensify and enhance applied products and to prolong wear time.

In addition, eyeliner has evolved from traditional pencil or powder applied to the skin above the lash line into a technique called “tightlining,” which involves forced application of product within the upper lash line between the roots of the lashes. Product application can also include the upper or lower lid margin, known as the “waterline” by makeup aficionados. To enhance eye aesthetics, it is also a contemporary common practice to apply a waterproof product directly to the lower lid margin (waterline). Waxy concoctions are painted across the meibomian gland orifices daily, often repeatedly throughout the day.

How do these practices impact lid margin and meibomian gland function and health? What about the glands of Zeis and Moll? Do cosmetic enhancers, such as lid liners, occlude lash-servicing glands and encourage stye and hordeolum formation? Do remnants of cosmetics harbor microbes or promote biofilm formation? How do cosmetics impact cilia follicle health and the stem cell population that resides within them? What about the lashes themselves? Does makeup alter the normal adnexal microbial flora? How do the pigments, minerals, and waxes affect the balance of the ubiquitous mite (Demodex) population? Do these added substances enhance or retard commensal lid flora? Which substances prompt allergic responses? And what about the tear film? So many questions!

The Price of Eye Beauty

It’s not hard to believe that products applied to the lid margin find their way into the tear film more quickly compared to those applied to the skin at the lid margin (Ng et al, 2015). We also learned that long-term mascara use contributes to eyelash loss (Kadri et al, 2013). Of greater concern is the use of eyelash extensions that are applied (glued) to individual eyelashes. Eyelash extensions may cause ocular disorders such as keratoconjunctivitis and allergic blepharitis, and most glues for eyelash extensions contain formaldehyde, which can cause keratoconjunctivitis (Amano et al, 2012). And what effect does old-fashioned false eyelash glue have on the skin of the eyelids?

A Recommendation for All

Considering the potential pathology of applied eye cosmetics and prosthetics, removing them is paramount. Microexfoliation of the lid margin and pure hypochlorous acid solution can help remove accumulated lid debris and dampen bacterial and perhaps acarid loads. Interestingly, lid hygiene incorporated into therapeutic care for chronic allergic blepharoconjunctivitis improves secondary dry eye symptoms and enhances treatment effectiveness (Ianchenko et al, 2014). Finally, a consensus recommendation of the 2014 Dry Eye Summit for baseline management of dry eye includes nutrition, ocular lubrication, and lid hygiene for all patients (Morris, 2015).

So let’s prescribe lid hygiene for all of our patients…whether they wear eye makeup or not. CLS

For references, please visit and click on document #235.

Dr. Mastrota is Program Chair-Elect of the Anterior Segment Section of the American Academy of Optometry. She is a consultant or advisor to Allergan, B+L, BioTissue, NovaBay Pharmaceuticals, and OcuSoft and is a stock shareholder of TearLab Corporation. Contact her at