Aligning with Aesthetic Specialists

Several periocular aesthetic procedures performed routinely by aesthetic medical providers warrant a thorough baseline evaluation of ocular surface health before proceeding. This is because preexisting dry eye disease (DED) or incomplete blink can significantly increase their risk profiles. So, what are these procedures, how can we intervene, and what steps can we take to collaborate with aesthetic medical providers? What follows aims to answer these questions:

BLEPHAROPLASTY

Preexisting DED is considered the highest risk factor for worsening and persistent DED after blepharoplasty (Figure 1).^1-3 Cosmetic and functional blepharoplasty can worsen DED through multiple interconnected mechanisms, primarily involving disruption of the eyelid-tear film interface. Resection of the orbicularis oculi muscle may impair blink mechanics, reduce meibomian gland secretions, and compromise tear distribution and drainage. Meanwhile, possible postoperative complications, such as lagophthalmos, ectropion, and scleral show, further destabilize the tear film through prolonged ocular surface exposure. Additional contributors to DED include mechanical alteration of the corneoscleral interface, direct injury to the lacrimal gland, and chemosis-induced goblet cell destruction, all of which can perpetuate or initiate the evaporative cycle of DED.²

• How we can intervene. We should perform a structured preoperative evaluation that includes the documentation of corneal and conjunctival staining, tear breakup time, lid closure, and meibomian gland morphology (Figure 2). This way, we can provide this actionable data and collaborate with the aesthetic medical provider regarding the possible delay of procedures or treatments after the procedure.

Additionally, we should provide patient education on the value and results of the preoperative screening process. Further, we should discuss any possible postsurgical complications with the patient. This way, patients who undergo these procedures won’t be at risk of experiencing any unwelcomed surprises.

BOTULINUM TOXIN INJECTIONS

These may reduce orbicularis oculi contraction, diminishing blink amplitude and frequency, as well as decreasing tear clearance and distribution over the ocular surface.⁴ In patients with subclinical or established evaporative DED or incomplete blink and eyelid closure, botulinum toxin injections can cause an already unstable tear film to develop symptomatic disease.

• How we can intervene. In addition to performing the same structured ocular surface health evaluation detailed above, we should perform the eyelid snap-back test. This test allows for the early detection of eyelid laxity, so we can determine patient candidacy for neurotoxin injections in this region.⁵

LASH SERUMS

OTC and prescription lash serums have been associated with periorbital fat atrophy, conjunctival hyperemia, lid hyperpigmentation, and meibomian gland dropout.⁶

• How we can intervene. We should perform a baseline ocular surface evaluation on patients interested in these serums before they use them. Additionally, we should follow up periodically to monitor them for any changes in ocular health after use. This way, we can institute related effective treatment(s), if needed.

EYELASH EXTENSIONS

Complications related to eyelash extensions include allergic contact dermatitis, eyelash loss, eyelash base calcification, blepharitis, conjunctivitis, corneal abrasions, and keratitis.⁶ Additionally, mechanical trauma, blepharitis, and meibomian gland dysfunction (MGD) have been documented.⁶ Further, in patients who have preexisting lid margin disease, eyelash extensions may perpetuate or accelerate MGD.

• How we can intervene. We should perform a baseline lid margin evaluation and offer patient counseling regarding eyelash extension hygiene (Figure 3). This counseling should include tips, such as using hypochlorous acid sprays, as these sprays keep the lash line clean without irritating the eyes or damaging the eyelash extensions.

EYELID TATTOOS/PERMANENT EYELINER

Blepharopigmentation, or tattoo/permanent eyeliner, involves the process of using varied metallic pigments to permanently tattoo the eyelid skin, most prominently just above and below the eyelashes (Figure 4). It is a risk factor for the development of DED and the worsening of preexisting DED due to the metallic pigments and proximity to the ocular surface. Complications of tattoo eyeliner include MGD, tear film instability, increased fluorescein staining, and meibomian gland loss.⁷ Additionally, allergic granulomatous reactions have been reported, which can lead to eyelid scarring and eyelash loss and misdirection.⁸

• How we can intervene. Many patients are simply unaware of the risks involved here. Therefore, we can intervene by providing patient education on these risks. Additionally, we can help these patients byusing meibography to assess the health of their glands. Should patients elect to undergo one of these procedures, we should monitor them periodically after the procedure is performed to look for meibomian gland loss, chronic inflammation, and/or delayed allergic reactions.

When it comes to all the procedures discussed here, we should incorporate questions such as, “What cosmetic or functional procedures have you undergone?” and “What cosmetic or functional procedures are you planning on undergoing?”into the existing patient history/intake form. The answers to these questions will enable us to both prevent poor outcomes and prepare patients for optimal ones.

Additionally, we should review meibography and/or anterior segment images and staining findings with patients to empower them to play an active role in their ocular health.

ACTION STEPS

To collaborate with aesthetic medical providers, I suggest the following:

• Send them an invitation

Specifically, invite them to an open house at your practice to demonstrate examples of prescreening protocols (ie, meibography, fluorescein staining images, etc.) to show how you can benefit them and their aesthetic patients. This can make a positive impression, as the diagnostic devices we have and the objective data they provide are not typically part of the aesthetic specialist’s practice.

• Provide a lunch-and-learn

Educate the aesthetic medical specialist’s staff on DED and the importance of a prescreening and, possibly, related treatment prior to patients undergoing an aesthetic procedure.

• Invite them for a meal

Offer to take the aesthetic medical provider for a one-on-one meal, during which you learn about their practice and the procedures they offer, so you can match your skills with their needs.

• Provide a prescreening checklist

Consider giving them a prescreening checklist to incorporate into their consultations. This checklist should inquire about DED symptoms and identify chronic contact lens wearers, autoimmune disease, and any prior ocular surgeries.

• Develop a clear referral process

We can accomplish this by providing a referral form and a dedicated comanagement contact at our practice.

• Send concise consultation reports

We should provide these both pre- and postoperatively to keep aesthetic medical specialists in the loop on the presence of DED and its connection with each of the procedures mentioned above. Also, we should outline treatment protocols to optimize patient success.

THE BOTTOM LINE

Optometrists who prioritize ocular surface health, establish communication protocols with their aesthetic colleagues, and engage patients are in an excellent position to prevent unintended consequences and improve outcomes.