Steering Clear of Makeup Misuse Can Prevent Ocular Disease

Monica Dweck, MD, of New York Eye and Ear Infirmary of Mount Sinai, Nandini Venkateswaran, MD, of Massachusetts Eye and Ear, and Laura Di Meglio, OD, of the Wilmer Eye Institute, among other clinicians, offer guidance on advising patients on the ocular dangers of cosmetics abuse.

From mascara to eyeliner and primer to eye shadow, the use of eye cosmetics is practically prehistoric.1 But for as long as people have been using makeup to enhance the features of their face and eyes, there have been negative consequences, ranging from dry eye disease to allergic conjunctivitis and beyond. 

The global eye makeup market is enormous: data from 2018 places the estimated market size at $14.52 billion dollars, anticipated to grow by 5.7% between 2019 and 2025.2 In the US, the combined sales of mascara, eyeliner, eyebrow makeup, and eye shadow topped $882.13 million.3 It’s more likely than not, then, that ophthalmologists are treating patients who are daily eye makeup users — some of whom have poor ocular hygiene. 

Sleeping in eye makeup is one of the cardinal sins of cosmetics use, but how bad is it, actually?

“It’s bad. It’s really bad — there’s no way around it,” said Monica M. Dweck, MD, an ophthalmologist at the New York Eye and Ear Infirmary of Mount Sinai and senior faculty of ophthalmology and medical education, adding that eye makeup is a foreign substance that can lead to irritation, inflammation, and eye redness, especially in those prone to sensitivities. 

“A lot is happening when people are asleep that they’re not even aware of,” added Nandini Venkateswaran, MD, a cataract, cornea, and refractive surgeon at Massachusetts Eye and Ear and an ophthalmology instructor at Harvard Medical School. “There can be lingering makeup pigment, there can be bacteria, there can be dust and allergens … All of which are just sitting on the eyelids and eyelashes and migrating onto the ocular surface.” In addition to the usual complaints, patients can also develop styes or chalazions on the eyelid, eye dryness, and eye-related infections on the cornea or conjunctiva. 

“You’re leaving yourself open to festering bacteria that can grow on the eyelids, which can lead to problems down the road,” said Laura Di Meglio, OD, a primary care optometrist and ophthalmology instructor at the Wilmer Eye Institute at Johns Hopkins Medicine. “Sleeping in your makeup and having not only the makeup there that sticks, but tears collecting overnight — it’s a great environment for bacteria to grow.” 

External cosmetics migrating onto the ocular surface is well documented in the literature as well, with “numerous anecdotal accounts of tear film contamination” resulting from eye makeup use, identified during routine slit lamp examinations.1 This migration can be passive and inadvertent, but that doesn’t stop it from causing potentially significant problems for patients down the line. 

Meibomian Gland Dysfunction and Dry Eye Disease

Sleeping in eye makeup, improper daytime application, and improper nighttime removal practices all can clog the meibomian glands in the eyelids, a condition that, according to Dr Dweck, is both extremely common and “woefully underdiagnosed.” When makeup is covering the openings of the meibomian glands, she said, the oil gland can become inflamed, limiting oil expression and causing a multitude of symptoms such as evaporative dry eye. 

Research published in 2018 delved further into this topic, looking at the effect of debris on the quality of the lipid layer of the tear film.1 This mostly superficial layer is composed of a “complex mixture of lipids” that are secreted by the meibomian glands. When cosmetics migrate across the eyelid margin, they can contribute to the increase of debris in the tear film lipid layer, meibomian gland blockage, and meibomian contamination — and a subsequent increase in tear evaporation and dry eye.1

This isn’t a new mechanism, either: 2 observational studies published nearly 3 decades ago confirmed it. The results of 1 study uncovered a significant relationship between eye cosmetic use and a reduction in the tear film lipid layer thickness; results of another observational study found that women who wear eye makeup were less likely to “exhibit foaming at the inner palpebral canthus” compared with women who did not wear eye makeup — and this reduction in foaming was correlated with symptoms of dry eye.4,5 

“Meibomian gland dysfunction tends to be a chronic disease for which there’s no cure,” Dr Dweck added. “It can be managed, and it can be controlled, but there’s no cure.” 

The practice of tightlining — also known as invisible eyeliner — is an eyeliner application technique that involves lining the upper waterline to provide make lashes appear thicker and more defined, add structure and definition to the face, and create visual contrast.6,7 While makeup artists and beauty experts laud tightlining as a must-known makeup technique, ophthalmologists have a different take on the practice. 

“When you’re tightlining, you’re actually placing pigment right over the orifices of the meibomian gland,” said Dr Venkateswaran. “You can imagine, whether it’s water or pencil eyeliner, that that pigment is going to be dispersing throughout the meibomian gland area and right onto the surface of your eye.” 

She likens it to having dandruff on your scalp: when debris are clogging the opening of an oil gland, the oils can’t flow out freely. 

“Anything applied near the lash line can migrate onto the ocular surface,” added Ilyse D. Haberman, MD, Assistant Professor of Ophthalmology at the NYU Grossman School of Medicine and the Associate Residency Program Director at NYU Langone Health. “The meibomian glands…are needed to contribute to the oil aspect of your tear production [and so] it’s important to not wear eyeliner on the waterline. Makeup should be limited to the skin.” 

And according to Dr Di Meglio, there’s the very real potential that the meibomian glands can die out following repeated application of eyeliner to the waterline: “If those glands die out, they can be gone forever… If you’re putting eyeliner along there, you’re giving yourself a little bit more of a chance of having gland dysfunction. If the oil stays stagnant…the glands themselves can atrophy.” 

Demodex folliculorum Infections

In addition to eyeliner, mascara is a primary offender in ocular surface diseases and inflammation, as well as Demodex folliculorum infections.8 Although Demodex has been found in lipstick and powder cream, mascara is one of the most common breeding grounds for Demodex, with an average survival time of 21 hours.8 According to researchers, the primary components of mascara are water, Copernicia cerifera cera, cera alba, glyceryl stearate, Euphorbia cerifera cera, and stearic acid. Water, they wrote, provides Demodex mites with the necessary humidity to thrive, and the effect of wax extracts from Copernicia and Euphorbia cerifera cera and remain unknown.8

Demodex can grow on basically anything that’s not properly cleaned,” said Dr Di Meglio. These mites can lead to both anterior and posterior blepharitis, leading to loss of eyelashes due to inflammation, swelling, erythema, and ulcerations, according to Dr Dweck.9 “Makeup can contribute to this pathogenesis if it’s not removed properly. Unfortunately, a big culprit of this is waterproof makeup, because it’s more difficult to remove. I’m not saying don’t use it — but make sure it’s removed completely.” 

And it’s not just faces that need cleaning.  “Buildup of bacteria and even Demodex mites can occur on makeup applicators over time,” said Dr Haberman, including on mascara wands, and they eventually end up in the eyes. 

Demodex treatment can be relatively straightforward, but requires upkeep and participation in a regular lid hygiene regimen. Walking patients through a regimen for home treatment requires patience. First, consider explaining the benefits of a simple warm compress to help loosen impacted debris and meibomian gland oils. It can even be pitched as a relaxing nighttime routine. Patients can follow these compresses with lid scrubs, which they can make themselves using diluted baby shampoo and applied with a textured applicator, or purchase over the counter. 

For particularly difficult cases, patients might require the addition of tea tree oil, an effective agent for treating Demodex infestations.10,11 More recently, group of researchers led by Jennifer P. Craig, MD, of the Department of Ophthalmology at the New Zealand National Eye Center and the University of Auckland in Auckland, New Zealand, found that cyclodextrin-complexed Manuka honey had a comparable efficacy to 50% tea tree oil in treating ocular Demodex.12 

Outside of Demodex, mascara can also lead to conjunctival pigmentation. The nylon fibers found in mascara can embed into the lash line and further, into the eyelid margin. They can also, according to Dr Venkateswaran, emit pigment. “You’re getting debris constantly falling onto the surface of the eye and potentially embedding onto the ocular surface,” she said. “I’ve noticed that patients can get lid swelling, inflammation of their conjunctiva, and even allergic conjunctivitis as a result of mascara use.” 

This complication was illustrated in 2 recent case studies: In the first, a woman in her 60s sought a second opinion after a presumptive diagnosis of conjunctival melanoma.13,14 After an unremarkable evaluation, her physicians found deposits of “excessive eye makeup and bilateral inferior conjunctival pigmentation” in a patchy, linear pattern.13 Pathology, however, was normal; submucosal tissue indicated mild, sparse chronic inflammation and pigment-laden macrophages, consistent with a diagnosis of mascara-induced conjunctival pigmentation.15

The second case highlighted the pigmentation of the conjunctiva and the nasolacrimal sac, common when “macrophages ingest pigmented material” that settles in the substantia propria of the epithelium. Histopathology of a 62-year-old woman showed significant pigmentation of fibrous tissue in the cytoplasm and the stroma consistent with mascara use. Physical findings such as these, the authors noted, can be used for accurate diagnosis of mascara-related ocular conditions.14 

Simple things — such as swapping regular mascara for waterproof versions or using organic mascaras — can be conducive to creating a healthier ocular surface, Dr Venkateswaran noted, adding that for patients who are particularly sensitive, a mechanical eyelash curler may be the way to go.14