Why should optometrists consider offering aesthetics-related services and products? Consider these five reasons:

1. Such services and products go hand in hand with treating dry eye disease (DED), which affects 6.8 % of the U.S. adult population, or 16.4 million people.¹

2. Ocular surface and lid health are in the OD’s wheelhouse.

3. Eliminating causes of inflammation around the eyes from toxic makeup ingredients, telangiectasias, overgrowth of biofilm, inspissated meibomian glands, and laxity of the eyelids also improves the appearance of the signs of aging around the eyes. Patients appreciate this.

4. Three out of four of the most-used makeup are eye-related (mascara, eye shadow, and eyeliner), according to Cosmetics & Toiletries, a peer-reviewed cosmetic science resource.

5. Adding this specialty, by virtue of the services related to it, can increase practice revenue.

Following these steps can enable you to provide this optometric specialty*:

1. Educate on eye health
Educate your patients on the effects that cosmetic practices and procedures can have on eye health, to get them primed to hear about how they can safely continue to use cosmetics. For example, the Tear Film & Ocular Surface Society’s (TFOS) Global Workshop, “A Lifestyle Epidemic: Ocular Surface Disease,” describes cosmetics and their effect on the ocular surface (see bit.ly/TFOSGlobalWorkshop). Armed with this knowledge, you can explain to your patients the effects cosmetics have on their own eye health and make it personal.

Topics you may want to cover:

• Cleaning eye lash extensions properly. Eyelash extensions can have the adverse side effects of DED, conjunctivitis, and corneal infections, among others. For those patients who won’t cease use, show them how to properly clean their eye lash extensions. Instructions can be found in several online resources including “The Optometrists Guide to Eyelash Extension Care V2.0” by Tanya Gill, OD, the founder of We Love Eyes (see bit.ly/WLELashcare).

• Retinol-containing creams have the ocular side effects of damaging meibomian gland structure and reducing meibum secretion. As an alternative, radiofrequency (RF) treatment (discussed further below) reduces fine lines and wrinkles around the eye without harming surrounding tissues.

2. Offer in-office interventions 
Once patients understand the connection between cosmetic practices and eye health, offer in-office interventions (i.e., beneficial products and procedures), pointing out that these interventions should enable them to wear makeup safely.

• Products. I recommend you start by offering the most popular items, to increase the likelihood of dispensing. These items: makeup remover, mascara, and an eyelash-enhancing serum. Once you achieve success in dispensing these products, consider adding others, such as eye shadow sticks, eye liner, and using an online partner to ship the products directly to your patient’s home.

I have achieved patient buy-in to the products I provide by using scripts that highlight the problem and the solution I offer. Additionally, I explain that my interventions are free of toxic ingredients that can harm the lids or ocular surface.

Here’s an example of a patient script:

“Mrs. Jones, I see a lot of powdery particles floating in your tears today. This is most likely from your eye shadow falling into your eyes throughout the day. This can cause micro-abrasions, inflammation, and irritation to your eyes. I suggest you switch to a cream or crayon-based eye shadow, or use a primer under your powdered eye shadow. We stock my favorite eye shadow sticks here. Would you like us to show them to you?” 

For patients hesitant to use the interventions I offer, I ask that they visit the Skin Deep Database, from the Environmental Working Group (ewg.org/skindeep), to determine whether the cosmetics they currently use are as safe as what I offer. This request makes quite an impact. (See “Eye Makeup Wear and Care Rules,” above.)

Because DED is linked with cosmetic use, it makes sense to also offer ocular hygiene products to keep the lids and ocular surface healthy. As per the TFOS DEWS II workshop, these include:

- Artificial tears, which reduce the osmolarity of the eye and flush out irritants.

- Lid and lash cleanser, which control any overgrowth of bacteria around the eyes.

- A warm compress mask, which heats the meibomian glands and promotes the flow of oils.

- An omega fatty acid supplement, which provides the body with the building blocks it needs to produce healthy tears.

- Other lid hygiene products available, such as moisture goggles.

I also provide patients with a hand-out that describes environmental modifications, such as using ambient humidifiers.

• Procedures. The following procedures benefit both the function and structure of the eye, while providing the side effects of a healthy appearance: micro-blepharoexfoliation, intense pulsed light (IPL), RF, RF with microneedling, and injections and fillers.

A micro-blepharoexfoliation device removes biofilm, including staphylococcus bacteria and Demodex, from around the eyes, promoting meibomian gland function and reducing inflammation and redness.³ Doing so eliminates redness. This procedure should not be performed when the patient is wearing lash extensions.

IPL improves tear breakup time (TBUT), meibum quality, lipid layer thickness, Schirmer test scores, and the appearance of irregular blood vessels that appear in the cheeks and eyelids.⁴ Be sure to advise the patient to wear sunscreen after treatment.

RF followed by meibomian gland expression improves TBUT, corneal fluorescein staining, and meibomian gland score, while stimulating collagen production and tightening the skin around the eyes, which reduces wrinkles.⁵

RF with microneedling can enhance overall eyelid structure, promote meibomian gland health by stimulating blood flow and promoting tissue regeneration, and help to improve skin laxity, and reduce fine lines and wrinkles.⁶ Microneedling is comprised of using fine needles to create controlled micro-injuries in the skin, stimulating the body’s natural healing response and triggering collagen production.

Injections, such as onabotulinumtoxinA, will reduce fine lines and wrinkles, but due to potential damage to the meibomian glands, I do not recommend them within the lid area. Fillers, however, can be used under the eye to plump the appearance of under eye hollowness and reduce dark circles.

Please note: The ability to provide these procedures depends on state scope of practice laws, so be sure to consult your state optometric association.

3. Bundle products and services
To increase the likelihood of your patients using all the products and services that can preserve their ocular health and healthy appearance, consider bundling them together. From a psychological perspective, bundling can enhance the consumer’s perceived value. This is because they see the total value of the bundle as higher than the amount of the value of the individual items, particularly when one price is listed, according to Omnia Retail, a pricing software company.

Additionally, improvement in DED due to MGD using a series of four treatments combining IPL, RF, and meibomian gland expression, resulted in improvement in both DED symptoms and signs.⁷

At my practice, I’ve had success in bundling four sessions of IPL with RF using a rosacea-friendly facial cleanser, moisturizer, and sunscreen, as well as products to support continued lid hygiene. I bundle everything together, so that the series of four procedures and the products come together as one price. 

You could also consider bundling smaller packages like micro-blepharoexfoliation plus lid and lash cleanser and a warm compress. Or, just your dry eye starter kit of products, like artificial tears, lid and lash cleanser, warm compress, and nutritional supplement could also work. 
I’ve found that bundling and making the offer to patients before they leave the office improves their adherence to the treatment plan recommended.

A beautiful niche
Getting started doesn’t have to be hard. Begin educating your patients about the importance of eliminating toxic ingredients in the products they’re already using around their eyes and how they affect their eye health. Next, talk with your patients about their eye health and their aesthetic concerns about the appearance of their eyes. Finally, add products and procedures that support your patients, and consider bundling. OM

* Note: Before offering any cosmetic/aesthetic technologies, products or services, check with your state board of optometry to ensure you are following all appropriate state guidelines, which may include informed consent, and billing and coding rules. 

References

1. Dry Eye Disease. UpToDate. https://www.uptodate.com/contents/dry-eye-disease#:~:text=Based%20on%20data%20from%20the,diagnosed%20with%20DED%20%5B3%5D. (Accessed April 25, 2024.)

2. Sullivan DA, da Costa AX, Del Duca E, et al. TFOS Lifestyle: Impact of cosmetics on the ocular surface. Ocul Surf. 2023;29:77-130. doi: 10.1016/j.jtos.2023.04.005.

3. Zhu D, Gupta RR, Stein RL, et al. Randomized Prospective Evaluation of Microblepharoexfoliation BlephEx as Adjunctive Therapy in the Treatment of Chalazia. Cornea. 2023;42(2):172-175. doi: 10.1097/ICO.0000000000003090.

4. Barbosa Ribeiro B, Marta A, Ponces Ramalhão J, Marques JH, Barbosa I. Pulsed Light Therapy in the Management of Dry Eye Disease: Current Perspectives. Clin Ophthalmol. 2022;16:3883-3893. doi: 10.2147/OPTH.S349596.

5. Paul S, Cohen A, Parsa K, Jaccoma E, Burrell K, Carruthers J. Transcutaneous Radiofrequency-mediated Meibomian Gland Expression is an Effective Treatment for Dry Eye: A Prospective Cohort Trial. The Open Ophthalmology Journal. 2023 17. 10.2174/18743641-v17-e230328-2022-63.

6. Lim YK, Jung CJ, Lee MY, Moon IJ, Won CH. The Evaluation of Efficacy and Safety of A Radiofrequency Hydro-Injector Device for the Skin around the Eye Area. J Clin Med. 2021;10(12):2582. doi: 10.3390/jcm10122582.

7. Chelnis J, Garcia CN, Hamza H. Multi-Frequency RF Combined with Intense Pulsed Light Improves Signs and Symptoms of Dry Eye Disease Due to Meibomian Gland Dysfunction. Clin Ophthalmol. 2023;17:3089-3102. doi: 10.2147/OPTH.S426564.

PAMELA E. THERIOT, OD, FAAO is the clinical director of the Dry Eye Relief Center at Lusk Eye Specialists, a multi-location practice in Louisiana. In 2021, she was appointed to the Public Awareness committee of the Tear Film and Ocular Surface Society (TFOS). She created a Dry Eye Relief Blog that contains tips and product recommendations for dry eye patients.