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Beauty and the delivery of aesthetic medical care continues to appeal to the masses. Industry numbers show steady growth over the past several years: 2016 saw a spending increase of $1.5 billion in aesthetic procedures, 46% of which was spent on non-surgical procedures alone.1 Although not widely known, nonsurgical aesthetic procedures are growing more popular in our male patient populations—particularly in the area of facial aesthetics.
In 2016, men made up 9.9% of botulinum toxin type A (Botox, Allergan) procedures and close to 9% of all nosurgical procedures in cosmetic procedures overall.1 They are readily embracing numerous tactics to maintain their appearance, including laser hair removal, photorejuvenation, chemical peels, and injectables such as botulinum toxin type A (Botox; Dysport, Galderma; and Xeomin, Merz) and hyaluronic acids.1 Advertising in this area typically panders to gender stereotypes, but, with men looking to go from Gere to Gosling, optometrists should be providing services and education to more than just their female patient populations to open up this conversation.
BOTOX IN A BULB
Intense pulsed light (IPL) has emerged in eye care for the treatment of meibomian gland dysfunction. It has also been a major player in dermatology for collagen remodeling and thrombolytic activity on telangiectatic blood vessels.2 The aesthetic impact of IPL on the periocular tissues and skin can effectively address an unmet need in our patients while addressing their dry eye disease concurrently. The known mechanism of action of IPL for meibomian gland dysfunction is initiated through the application of visible light across and below the eyelids from ear to ear.
Optometrists use a xenon flash lamp at 500 nm to 1200 nm for the procedure, which results in blood cell coagulation and closes off aberrant blood vessels in neighboring regions.3 Additionally, IPL may inhibit the release of cytokine via mitogen-activated protein kinases (MAPK) in fibroblasts, thereby rejuvenating the skin.4 This helps to restore skin tension and complexion in the area, adding to its cosmetic capabilities. IPL will not only advance dry eye practices, but this photo-pharmacy may also become Botox in a bulb for periocular skin care.
Radiofrequency (RF) heat is the application of high energy radio waves (0.3 MHz to 10 MHz) that causes nonablative thermal damage and induces new collagen growth in deep and subcutaneous skin.5 RF heat has been used in dermatology for nonsurgical skin lifts over the past several years. Although present in some eye care practices, RF is underrepresented given its list of indications. Fine lines of the periorbital and eyelid region, eyelid hooding, and maintenance of cosmetic surgery can be managed by RF technology.
In a survey by the American Geriatrics Society Foundation for Health in Aging, 9 out of 10 patients feared loss of strength as a one of the most dreaded aspects of aging.6 Wrinkles are visible signals of weakness, causing concern for some of our male patients—although they may not communicate this openly. With the increasing number of men engaging in aesthetic medical services, it would seem that safe, nonsurgical options such as RF may have a place in more eye care practices. Currently, systems like Pelleve (CynoSure) and Thermage (Valeant) are two of several RF systems being used in the aesthetic eye care space.
CLEANSERS AND FACIAL PRODUCTS
Per the advice of the Dry Eye Divas—the trio of Laura Periman, MD; Leslie O’Dell, OD; and Amy Gallant Sullivan, MS—I have incorporated cosmetic forensics into my ocular surface workup, which consists of a detailed history and includes usage patterns of all skin products and make-up. While I found the make-up offenders in my female patient populations easy to uncover, identification of male patients who used skin products was more difficult to detect. I have found that male patients in their mid-20s to mid-50s used a wide array of facial cleansers and antiaging lotions. Upon closer examination of the ingredients in common skin care products, I found that many ingredients were not kind to the ocular surface. As noted in the Divas’ AOC series, preservatives such as BAK and phenoxyethanol are known epitheliotoxic agents. Additionally, formaldehyde-donating preservatives such as DMDM hydantoin (Glydant, Lonza), quaternium-15, and sulfonylureas are suspected corneal nerve irritants.6,7
I found a large number of men in the pursuit of youth using all-trans retinoic acid, or Tretinoin, for fine wrinkle reduction in the periorbital regions, which turned out to be adding to their poor tear film. Tretinoin has demonstrated a potential to harm meibomian glands, increasing evaporation stress at the ocular surface.7 We see this often in DED patients in whom the need to squint and purse their eyelids to reduce exposure results in the very same age lines for which they are apply antiaging cream. It is easy to see how the two conditions exacerbate each other.
By simply examining the skin products that they use, our team was able to uncover the overlooked truth about our male patient populations: Although they may not have been specifically requesting aesthetic advice, they were seeking it at their local cosmetic counters and retail pharmacies.
The increasing availability of technology to rejuvenate the ocular surface has led to an inadvertent win for our patients’ aesthetics needs. This has opened crossover opportunities between dermatology and eye care, and it requires clinical consideration of the patient first without stereotyping by gender. The evidence shows that men seek aesthetic services in increasing numbers despite marketing campaigns largely geared toward females. With this unmet need and new treatments in eye care to provide these services, it seems optometrists are poised to become a new access point for aesthetic eye care.
From the BMC Archive
By Leslie E. O’Dell, OD; Amy Gallant Sullivan, MS; and Laura M. Periman, MD Advanced Ocular Care Volume 8, Issue 1
1. American Society for Aesthetic Plastic Surgery. 2016 Cosmetic surgery national data bank statistics. https://www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf. Accessed July 25, 2017.
2. Ganceviciene R1, Liakou AI, Theodoridis A, et al. Skin anti-aging strategies. Dermatoendocrinol. 2012;4(3):308-319.
3. Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction. a 3-year retrospective study. Photomed Laser Surg. 2015;33(1):41-46.
4. Huang J, Luo X, Lu J, et al. IPL irradiation rejuvenates skin collagen via the bidirectional regulation of MMP-1 and TGF-β1 mediated by MAPKs in fibroblasts. Lasers Med Sci. 2011;26(3):381-387.
5. Araújo AR, Soares VP, Silva FS, et al. Radiofrequency for the treatment of skin laxity: mith or truth. An Bras Dermatol. 2015;90(5):707-721.
6. AGS Choosing Wisely Workgroup. American Geriatrics Society identifies five things that healthcare providers and patients should question. J Am Geriatr Soc. 2013;61(4):622-631.
7. Epstein SP, Ahdoot M, Marcus E, et al. Comparative toxicity of preservatives on immortalized corneal and conjunctival epithelial cells. J Ocul Pharmacol Ther. 2009;25(2):113-119.
8. LE, O’Dell, AG, Sullivan and LM, Periman. Beauty does not have to hurt. Advanced Ocular Care. 2016;7(5):42-46.
Richard Maharaj, OD, FAAO
• clinical director, eyeLABS Optometry and Center for Ocular Surface Disease, Brampton, Ontario; senior optometrist, York-Finch Eye Associates, North York, Ontario; clinical associate faculty, University of Waterloo School of Optometry, Waterloo, Ontario
• financial disclosures: Allergan, IMED pharma, Johnson and Johnson Visioncare Canada, Santen, Shire, TearScience