Counseling Patients on Ocular Cosmetic Procedures

“Beauty is in the eye of the beholder.”

“The eyes are the windows to the soul.”

How many expressions do you know that equate eyes with youth and beauty? As a primary focal point on our faces, we are always trying to keep ourselves looking fresh and young. And as a larger proportion of our patients (especially the baby boomer generation) advances in age, we as primary eye care doctors need to be able to counsel patients considering different procedures and devices and offer professional opinions on the associated risks and benefits to allow patients to make the best informed choices.

Limbal-Defining Contact Lenses


Within the last few months, Vistakon launched a new 1-day colored/enhancement contact lens that is primarily colored around the limbus, based on research that more defined limbal rings are interpreted as “more youthful.” The 1-Day Acuvue Define lenses are available in a range of eye colors and in several different patterns such as “sparkle” and “shine.” While the perception of this may be partially a placebo effect, the truth is that patients do lose pigment around this area with increasing age, and it is often more apparent in patients with darker eyes. This is in addition to patients that develop arcus senilus, which regardless of eye color, will deposit a light band of cholesterol at the limbal margin. These lenses can cover said ring with a light ring of color to increase patient confidence if contact lenses are not contraindicated. This can be a practice builder as the lenses are already FDA approved as one day disposable lenses. However, since the lenses are expensive, patients may try and “stretch” pairs for longer than their intended use, so monitor carefully. Plano patients desiring just cosmetic fits tend to misuse lenses the most. Educate patients on proper contact lens care (which in this case is one day disposable). If cost is a concern but the patient still desires the effect of the lens, consider fitting them in an Acuvue 2 Colours lens similar to their natural eye color.

Tattooed/Permanent Eye Makeup

Many women consider getting permanent eye makeup such as eyeliner or eyebrows as a means of cutting minutes of precious time off their daily morning routines. If the patient is willing to accept the risk that the ink is permanent (and in this case laser removal is not an option due to the proximity to the eye), the risk to the eye is not great during the actual tattooing process seeing as the ink penetrates only skin. However, counseling your patients on how the look may change over time with aging is crucial. Eyelid skin droops and the line may not look the same at 65 as it does at 25. Similarly for the eyebrows, the forehead muscles are not immune to aging and will likely look different with aging. One procedure that has seen popularity in the prison system and with underground tattoo artists is injecting ink directly under the conjunctiva. This can range from black ink to completely “black out” the look of the sclera, or change the color to blue, green, etc. This is not a practice any OD should recommend to patients, but should be aware is being done.


Possibly one of the most common cosmetic surgeries, eyelid lifts are rising in popularity for cosmetic (and functional!) reasons. As patients age, the levator muscle attachment slips and we see this present as ptosis and dermatochalasis. Patients complain because they have looser lids, redundant or baggy skin on their eyelids, and some will even lose superior visual field if it gets to be too bad. The last point is where we can come in and help patients get a functional surgery rider. When patients want surgery on their lids simply because their lids are sagging, that’s a cosmetic surgery. But when we can prove to an insurance company that the visual field is affected, that’s another story. How we do this is using our Humphrey Visual Field. One field is done with the patient’s natural lid condition. Then using surgical tape or gauze, we tape the lid to the brow bone, simulating how it would be if the patient had the surgery and re-test. If the fields meet the particular criteria (usually 25-30% field improvement), insurance will usually cover the lid surgery for the patient.

Blepharoplasty can be broken into upper  and lower, but functionally only upper is of substance for visual fields. Lower eyelid lifts are usually thought of as “getting rid of bags.” Also increasing in popularity within certain Asian populations is blepharoplasty to create an upper eyelid crease where there previously was a monolid. Almost all eyelid surgeries have very low complication rates when performed by a board-certified Plastic Surgeon, but remember patient age, motivation, and follow up in every decision. Remind patients that the procedure is still a surgery and to follow the instructions regarding care and medications. Increased patient age is also a factor and may slow healing, and patients may need to allot more time off work/not driving, etc. when making these decisions.

Laser Removal of Iris Pigment (Turning Brown Eyes Blue?)

The potential of baby blues through a laser outpatient procedure seemed like a dream until it hit the airwaves a few months ago. Seeing as only 8% of the world boasts baby blues, one could see why this would be a procedure that would appeal to some. The procedure has been “tested” on a small subset of patients and claims to remove the melanin granules from the melanocytes in the iris. Given that everyone has melanocytes (even blue eyes) but only dark eyes are full of melanin, this feasibly makes sense. Where we see a problem is where all this loose melanin is going to go. Immediately what comes to mind is Pigment Dispersion Syndrome (PDS) being artificially created. Rather than the iris bowing backward onto the iris and having the pigment rubbed off that way, it’s being blasted off with a laser. The pigment isn’t going to be sucked out of the anterior chamber, so it’s going to get stuck in the trabecular meshwork, the same way loose iris pigment does in pigment dispersion. Some would likely settle in the other places of PDS (endothelium, anterior lens) as well. Where this becomes a problem is when the patient’s IOP begins to rise, or worse, spike. This becomes pigment dispersion glaucoma, and all for a change in eye color that could have been changed with contact lenses. Blue eyes are nice, but are blind blue eyes worth it?

Eyelash Extensions

This is one semi-permanent “procedure” that I tried out for myself. Instead of using removable glue to glue a false lash in a strip on, an esthetician will use permanent glue (basically superglue) to attach individual synthetic or mink lash fibers to the natural lashes using tweezers. The client is reclined with their eyes closed and the bottom lashes are taped over to protect them from getting any glue on them. The end result depends on the desired effect and the lashes used, but typically results in longer, darker, and more voluminous lashes. How dramatic the results can be depends on how many extensions are applied. Typically the initial application of lashes takes 2 hours, and as the lashes naturally fall out (this happens normally), the salons recommend “refilling” every 3-4 weeks. This is supposed to be a shorter appointment. However, I found that even with impeccable care, the set I had applied looked amazing for about 5 days and then they began to clump, turn down into my eye, and began to become VERY uncomfortable to wear. There was no way they were staying on for 3 more weeks, so I had them taken off. A good amount of my natural lashes were lost in the process, and it will take some time for the “lash growth cycle” to replace them. This is a growing trend, and salons are popping up all over the place. Be on the lookout for your female patients with eyelash extensions. Under a slit lamp, you’ll be able to see the delineation between the lash fiber and the natural lash. In extreme cases the lashes can turn down and cause corneal abrasions, or the lashes can fall off and get lodged in the eye and cause infection, abrasion, etc., in addition to the natural lash line being either damaged or destroyed. The glands can be affected as well, causing or worsening meibomian gland dysfunction (MGD) and dry eye. This is a procedure that I don’t recommend personally, but it was worth the experience of going through it so that I can tell patients who experience thinning lashes that I personally don’t recommend this procedure. If patients ask your opinion on it, Latisse is a better option that you can prescribe for them! That way you know you are recommending an FDA labeled product for this exact purpose which has been known to work for hypotrichosis, with no risk of lashes being ripped out.

False Fiber/”3D” Mascara

This is a trend that has become increasingly popular with the direct sales crowd (i.e. having “online” or in person parties and demos). The product promises fuller, thicker, and longer lashes with only mascara and no commitment to the aforementioned extension hassle. While the first coat of mascara goes on as a typical one would, the second layer contains very fine fibers that adhere to the wet lashes, which are then coated over again, to “seal” them in. Over the course of the day with blinking or any touching of eyes or lashes, those fine fibers can be dislodged and make their way into the eye. The fibers are too small for the patient to see with their naked eye but can cause a very painful and uncomfortable foreign body sensation (FBS) depending on whether they sit on the cornea or conjunctiva. There have been several reports of cases like this reported on ODs on Facebook, encouraging doctors to educate patients not to purchase this (expensive!) product due to the inherent potential risk. Pictured to the left is a first hand account of a patient’s experience with fiber lash mascara, leading to a conjunctival abrasion.

I have tried this product in the past, and even with soft contact lenses on (essentially protecting my corneas from feeling any of the fibers), I felt awful FBS within 1-2 hours and had to remove the product. This was about 5-6 years ago before the large boom of the product I’ve seen recently. I expect to see more complications in the upcoming months to years. I don’t recommend the product, and if women are looking for a temporary solution to fuller eyelashes, I recommend temporary glue and strip lashes from a beauty supply store or the drugstore. Fake lashes are easily removable, and the entire strip won’t get easily lodged into the eye.

Ocular “Tattoos”

When optometrists don’t have injection privilege in most states, what is terrifying is that some patients who are looking for new methods of body modification are turning to tattoo artists for eyeball “tattoos.” Made popular first by several patients in the prison system, black ink is injected under the conjunctiva to “black out” the entire eye for an almost satanic/demonic appearance. The sclera isn’t permanently dyed, but the dye remains under the transparent membrane and the eye appears colored. This obscures the view of the vasculature, and can make the entire eye look one color if the patient has dark brown irides.

Since this initial presentation was seen with the eyes “blacked out,” more people are having the procedure done with less obvious ink colors like blue or green. While it is unclear if the pigment will fade over time like a tattoo, removal (if the person desires later on) will likely be difficult or impossible. Standard tattoo removal requires eye protection from the hazards of the laser, and it’s very unlikely there would be a process developed anytime soon to break up the pigment in the eye safely. Patients considering this “procedure” should be advised that it is permanent among potentially infectious, and the eye always has the potential to reject the pigment in an inflammatory manner. The novelty of it leaves us very uncertain about potential risks and complications.

In the quest to stay young in a world that is continually increasing in life expectancy, we need to be sensitive to the needs and desires of our patients. The face is the first thing we look at when meeting new people, and studies show that teeth and eyes are the two features we look at first. Be familiar with these ocular cosmetic procedures so you will be better able to counsel your patients and offer advice with their best interests and health in mind.

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