To complement this week’s CPD feature on cosmetics, this particular article shows a range of patients where, in some capacity, their use associated with cosmetics has contributed to a problem or, conversely, appropriate advice about the cosmetic offers helped with the particular management of the patient.

Case 1

Presentation

Fifty-four-year-old female, DC, attended for a routine vision test, her first for three years. Over this time, she had noticed the girl reading vision had deteriorated to the point that, reluctantly, she had been using a pair of readymade readers (+1. 50DS) for evening reading. She hated wearing these as the girl felt spectacles ‘ruined my looks’. Otherwise, her vision was good and there were no reported asthenopic symptoms.

DC worked in a canteen inside a busy office block and spent the work day moving between a very hot plus humid environment to a cool, dry air-conditioned atmosphere. Not only was this another reason to avoid specs (‘they keep steaming up’), but over the summer she experienced found her eyes starting to become ‘stingy’ and the girl vision ‘misty when I blink’. Things had improved a little since, one month ago, she got ceased in order to use eyeliner but, hating no make-up, she still used the mascara (applied and removed daily).

General health was good, simply no medications were taken and all other health plus history details were unremarkable. Because of her hectic job, she spent most weekends on country walks to ‘wind down. ’ She tended not to use sunspecs, again because the lady ‘doesn’t like the look. ’

Main concern

Halfway through the slit-lamp examination, DC suddenly sat back and asked ‘what do you think it is? ’ Seeing the puzzlement, she said that will her main worry was the increasing ‘bagginess’ of the periorbital skin beneath the brow, especially over the girl right eye. She then went on in order to describe how her mother had, in her sixties, had the same thing happen and that, eventually, her skin drooped so much that the girl paid for cosmetic surgery. DC wanted an opinion on this particular; specifically, whether such surgery for her now would avoid the later changes that had so much upset the girl mother.

Relevant clinical findings

Visions: R & L; 6/4

Refraction:

• L: +0. 25/-0. 25 x 95 (-0. 1)
• L: +0. 25/-0. 25 x 80 (-0. 1)
• R& L: N5 with +1. 50

Binocular status:

• Ortho distance and 3Δ XOP @ 40cm, great recovery
• Convergence to nose
• Motility in order to nose

IOP:

• 15mmHg R& L GAT @ 09. 56

Full threshold fields plus OCT: normal findings

Ophthalmoscopy: unremarkable and healthy throughout

Anterior:

• Skin over superior orbital rim slightly elevated, more noticeable on right, and slightly flaccid upon palpation (figure 3)
• No evidence of ptosis either eye
• Lid margins show grade 1 meibomian gland dysfunction and quality 1 anterior blepharitis (Efron, figure 2)
• Fluorescein break-up time: eight seconds [email protected] (figure 3)

Figure one, 2 & 3 (Clockwise from top): Skin more than superior orbital rim appeared slightly swollen, was flaccid and loose on palpation, and the particular superior lid crease seemed exaggerated; Grade 1 MGD (Efron grading); Fluorescein break-up time of 8 seconds

Management

This patient provides presbyopia, low grade MGD and blepharitis affecting tear quality plus comfort, and has early dermatochalasis from the superior orbital area.

I suggested:

• Use associated with Blephasol Duo lid treatment, twice a day for any month minimum. With good compliance, this can be effective in the management of low-grade blepharitis and MGD and, as a consequence, low grade tear instability. ¹
• I recommended that, if wearing eye liner in future was important for her, I would send her details associated with products known to be inert in contact with the skin. We emphasised that will this should only be used anterior to the lash line.
• I actually explained the nature of presbyopia and the increasing need for the near correction. Because of her working environment plus her simple refractive error, I suggested she consider a trial of soft multifocal contact lenses. This option appealed to her, so the following trial lenses had been put aside:
  • Trial lenses: Clariti one day multifocal, silicone hydrogel, daily replacement: R +0. 25 LOW, L: +0. 50 LOWER
• I explained that the area she was concerned with was a common change in most people, usually starting around the fourth in order to fifth decade, known as dermatochalasis. This is due to excess eyelid skin, muscle or fat, which commonly occurs above the upper lid. In time, the particular subdermal elastic tissues and collagen fibres around the eyes are unable to maintain their own elasticity, losing their regular shape plus structure. As the pores and skin tissues begin to stretch and expand, excess skin starts to hang or droops downwards, further causing thinning of the skin, wrinkling and/or drooping. I was able to demonstrate this along with my own facial appearance (figure 4).
• I explained that any cosmetic intervention for aesthetic reasons has been always a personal choice and, though my advice was that, at this stage, prophylactic measures appeared the most sensible choice, ultimately the final decision was hers and she may wish in order to ask the particular opinion associated with a cosmetic medical specialist. And in case DC had been ever to feel that the change was in anyway interfering with her quality of life, that might be the time to consult further about possible surgical treatment.
• We reassured DC that dermatochalasis can only be considered in order to be inherited in that will anatomical shape and epidermis distribution tends to end up being familial. It might be reasonable, therefore, to expect some progression along the lines her mother had experienced, but this was by no means certain. However, any kind of preventative measures for this progression ought to be seriously considered now. These were discussed along with DC.

F igure 4: Appearance of dermatochalasis within a 57-year-old male

Discussion

Dermatochalasis cannot be prevented, but there are usually steps that anyone plus everyone can take to reduce its progression. Since dermatochalasis is the skin ageing issue, these types of steps revolve around one theme: great skin care.

To reduce the risk of developing dermatochalasis or minimising the risk of development, the following steps may help:

• Do not over-wash your face, as this particular can create more skin problems.
• Keep your skin well moisturised: this will help keep it healthy. For DC, I actually recommended a neutral aqueous cream with regard to regular make use of. I also suggested the lady maintained good hydration at work.
• Avoid smoking (not relevant here), excessive drinking (relevant), and other causes associated with dehydration
• Use a high factor sun cream (sensitive formulation) when outdoors from now on, and reconsider wearing great quality, large eye sunspecs, both to help with the particular skin and to maintain good attention health.

Case 2

Presentation

Patient ME, the 56-year-old female, attended to get a dedicated dry eye clinic appointment. This particular had already been prompted by her history of symptomatic dry eyesight of a few years, which had yet to become adequately addressed.

As is recommended before a full dried out eye disease examination, ME claimed to have not worn make-up for 3 days and was convinced she acquired removed it thoroughly three days back. For an accurate assessment of structures such as the meibomian glands as well because analysis of tear patency without any leached in chemicals, make-up removal is important prior to an appointment.

Initial observation

It has been immediately obvious, even to the naked eye, that will ME even now bore traces of make-up on the girl lids (figure 5).

Figure 5: Initial view from the (a) right plus (b) left eyes recommended the presence of residual make-up upon the lids and around the lashes. Also note the nasal and temporal pinguecula, leading to some discolouration, the irregularity of the inferior cover margin, suggesting a longstanding history of blepharitis. Also, whenever looking near the corneal reflex on the particular left eyes, note the significant debris within the tears

Slit-lamp examination confirmed these suspicions:

• Mascara residue on upper eyelashes (figure 6), greater concentrations temporally within both eyes
• Scattered carbon particles around lower lid margin and proof significant rip debris (figure 7)
• Pigment staining around some upper lash follicles (figure 8)

(Left to right) Figure 6: Mascara close to lashes and on inter-lash spaces; 7) Spread eyeliner debris around lower lid perimeter (red circles), and significant debris inside the tears, best seen via specular reflection near the particular bright corneal reflex (white arrow). Also, note the clearly demarcated top of the tear prism, indicating tear volume is likely to be over average value; 8) Yellow pigment residue, suggesting longstanding contamination of the affected lashes; 9) a) BlephEx system with replaceable heads. (b) Blephex application on the patient

Management

Before additional assessment could be carried out, the lid margins and lashes had to be thoroughly cleaned, debris eliminated and pores and skin exfoliated. This was performed easily and quickly using a rotary medical grade micro-sponge system; BlephEx (figure 9).

With just one application of the BlephEx to each lid, the particular surfaces were fully cleaned and evaluation could begin (figure 10).

Figure 10: Lids of individual from figures 5 in order to 8 after BlephEx therapy

Situation 3

Presentation

CB, the 26-year-old woman, attended for the routine eye test simply three weeks before her due date to give birth. Her primary concern had been occasional periocular irritation, most noticeable on the surface of the upper covers. CB said these areas occasionally ‘flared up’, plus became ‘itchy and blotchy’. Being so often the case, by the particular time the girl appointment came round, both areas had been calm and quiet.

Main concern

History plus symptoms revealed that CB had simply no visual or even ocular health concerns and this was confirmed by the subsequent test. Indeed, she confessed to having booked the test primarily to relieve the boredom associated with the last days of pregnancy.

That said, 1 point CB-FUNK became clear as the girl was questioned about her itchy epidermis and a history of atopy. This seemed that her recent skin irritation was something new and had never happened prior to pregnancy. However , regarding some years, now, CB has experienced to limit her use of eyeliner and mascara as, upon several occasions in the particular past, they had resulted in itchy or sore eyelids.

Related clinical results

Slit lamp assessment exposed grade 1 blepharitis about all eyelash lines (figure 11). All else (lids, adnexa, holes, ocular surface and anterior eye) made an appearance healthy. Though somewhat dry, there was no evidence at exam of signs of skin irritation on the upper cover brow places (figure 12).

Physique 11 (top): Grade one blepharitis; 12) External lids. (a) temporary, (b) nose. Left (c) nasal, (d) temporal. No evidence of dermatitis (bottom)

Administration

I described to CB-FUNK that, during pregnancy, it is very common for women to experience several skin itchiness and discomfort, with up to 90% having some experience associated with this in some point. ^two CB’s symptoms suggested sporadic, transient episodes of atopic dermatitis. Maintaining good hydration, and the make use of a good inert moisturising cream or even gel would seem appropriate at this point, and the lady was reassured not to worry. Obviously, were any new symptom of issue to appear from this important time, it was important intended for CB to discuss this with the girl GP.

Regarding CB’s keenness to try any brand new eyeliner or mascara that will might be better tolerated by her reportedly sensitive eyelids, I was capable to present (on a test basis) a few of the particular Eyes Are the Story range of ophthalmologist-formulated aesthetic products right now available in the UK (figure 13). Care has been taken in order to ensure that CB only applied the eye liner outside the lash margin (figure 14) and that mascara was used sparingly (figure 15).

Number 13: Eyes Are the Story cosmetics, including wimperntusche, skin cleanser, moisturising serum and eyeline

Shape 14 & 15 (left to right): (a) CB-FUNK applying eyeliner, (b) eye liner applied; Eyeliner anterior to lash collection only (right)

The plan is to review CB, ideally right after three months once, hopefully, her baby is born plus she has had a chance to try out the makeup.

• Eyes Are the Story will be distributed in the united kingdom by Positive Impact and further information is available at eyesarethestory. com .

References

1. Guillon M et al. Symptomatic relief associated with eyelid hygiene in anterior blepharitis and MGD. Eye and Contact Lens, 2012, Sep; 38(5): 306-12
2. Balakirski G, Novak N. Atopic dermatitis plus pregnancy. Journal of Allergy and Clinical Immunology, 2022, VOL 149, Issue four, 1185-1194

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