Eyeing Beauty

Bridgitte Shen Lee, O.D., FBCLA, lays out 5 eye health do’s + don’ts for patients passionate about beauty

As an optometrist focused on ocular surface disease (OSD), a woman doctor who wears makeup regularly, and a working mom who takes care of her physical health and appearance, I regularly discuss ocular cosmetics topics with patients.

Patients do not know what they do not know. Modern dry eye disease (DED) is a lifestyle disease.

In this Ocular Aesthetics column, I lay out the simple do’s and don’ts regarding makeup and other ocular cosmetics that you can recommend for your patients.

5 DO’S

  1. Seek an OSD-Focused Optometrist for Your Ocular Cosmetics Needs.
  2. Follow This Guide If You Are an Eyelash Extension or Falsies Devotee:
    Any OSD-focused eye doctor will recommend against regular eyelash extensions and falsies use, but many women—including doctors themselves—are devotees of this popular cosmetic trend.
    Find an OSD-focused eye doctor, obtain comprehensive ocular surface exam baseline data, then decide whether to continue based on the severity of test results/symptoms. See Table 1 (page 36) for what is considered a comprehensive ocular surface exam.
    For mild clinical signs and symptoms: Maintain daily lids/lashes foam wash, followed by preservative-free saline hygiene solution containing 0.01% pure hypochlorous acid (HOCl); use a preservative-free lipid-based tear supplement; and treat any underlying disease.
    For moderate to severe clinical signs and symptoms: Follow your OSD eye doctor’s recommended treatment plan.
  3. Avoid Cosmetics That Have Harmful Ingredients.
    What are they? See Table 2 (page 36) for explanations.
  4. Wear Facial (Physical) Sunscreen Daily.
    The secret to the best anti-aging facial cream is to wear a proper physical sunscreen (not chemical sunscreen) daily. Avoid vitamin A—retinyl palmitate or retinol—and oxybenzone (a synthetic estrogen). Instead, look for products with zinc oxide, 3% avobenzone, or mexoryl SX.
  5. See a Facial Plastic Surgeon and Cosmetic Dermatologist for Your Anti-Aging Goals.
    It is important to see an experienced facial plastic surgeon and a cosmetic dermatologist for the latest noninvasive aesthetic procedures and injections of botulinum toxin and fillers.
TABLE 1: What Is a Comprehensive Ocular Surface Disease (OSD) Exam?
Blepharitis (Anterior) Crusty and Sticky Eye Lids With Discharge, Dry and Irritated Eyes
Demodex (Eyelash Mites) Itchy Eye Lids, Crusty or Sticky Discharge, Dry, Red, or Irritated Eyes
Conjunctivitis Red Eyes, Foreign Body Sensation
Keratitis Light Sensitivity, Red and/or Painful Eyes, Foreign Body Sensation
Ocular Dermatitis Red, Swollen, Irritated, Tender, and/or Dry Peri-Ocular Areas
Periorbitopathy “Sunken” or Old-Looking Eyes—Common Side Effect From Prostaglandin (Isopropyl Cloprostenate) Eyelash Serums
Meibomian Gland Dysfunction (MGD) Burning and Watery Eyes, Fluctuating or Blurry Vision, Tired Eyes, Dry and/or Red Eyes
MGD Diagnostic Tests Lipid Layer Thickness (LLT) Score, Blink Test, Meibomian Gland Images and Functions Score
Dry Eye Disease (DED) Combinations of All of the Symptoms Above
DED Diagnostic Tests Osmolarity Score, Inflammation Score, Conjunctiva Staining Score
Tear Breakup Time (TBUT), Tear Meniscus (volume), Cornea Staining Score
Ocular Surface Disease (OSD) Combinations of All of the Symptoms Above
Follow TFOS DEWS II to manage OSD and DED identity and underlying causes.
TABLE 2: Harmful Cosmetic Ingredients and Their Undesired Effect on Ocular Surface Health
Eyeliners & Mascaras
Avoid Waterproof Eyeliners

Avoid “tightlining” to waterline along inner eyelid margins
Wax, Pine Tar Derivative

Benzyl Alcohol
block meibomian gland orifices

drying healthy meibum, tear film instability
Avoid Eyelid Tattoos (permanent eyeliner) Alkaline Anesthetics

Body Art Pigment
tear film instability, corneal staining

meibomian gland loss, chronic lid irritation

infections, mechanical injuries
Avoid Waterproof Mascaras Wax, Pine Tar Derivative block meibomian gland orifices, tear film instability
Eye Makeup Remover and Face Wash
Avoid Formaldehyde & Formaldehyde Donors Preservatives Paraben

inhibit meibomian gland cells, estrogenic effect

similar to BAK (below)
Avoid Non-Formaldehyde Donor Preservative Phenoxyethanol neurotoxicity, common label “paraben-free,” rose smell
Commonly Found in Waterproof Eye Makeup Remover BAK (Benzalkonium Chloride) epithelial cells, goblet cell, meibomian gland damage

superficial punctate keratitis (SPK), reduces wettability
Commonly Found in Face Wash Sodium Laureth Sulfates strips meibum (the good oil)
All chart information compiled by Bridgitte Shen Lee, O.D., FBCLA


  1. Do Not Sleep With Makeup On.
  2. Do Not Use Eyelash Extensions, Growth Serums, or False Lashes Without an OSD-Focused Optometrist’s Care.
  3. Do Not Tightline Eyeliner Over Your Waterline on a Regular Basis.
    It blocks meibomian gland orifices and leads to meibomian gland dysfunction (MGD) and dry eye symptoms.
  4. Do Not Use OTC Dry Eye and Redness Relief Drops Without Seeing an Eye Doctor First.
    Treat the underlying cause(s) of red eye and dry eye first. Many over-the-counter relief drops have harmful preservatives and ingredients.
  5. Do Not Follow What’s Popular in Social Media!
    Do not do these things: iris and conjunctiva tattoo, eyelid tattoo, urine drops, Sharpies as eyeliners, eyeliners with magnetic dust for magnetic falsies.

Primary eyecare doctors play an essential role in educating patients on why they should follow ocular cosmetics advice: to help them look and feel their best and to protect their delicate ocular surface. —BRIDGITTE SHEN LEE, O.D., FBCLA