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Patients must be educated about the side effects of bimatoprost. BY LESLIE E. O’DELL, OD Longer, fuller, thicker eyelashes are a highly sought-after beauty attribute and a big money maker for the cosmetics industry. A recent survey by the finance website Mint.com found that women spend an average of $15,000 on makeup in their lifetime, with $3,770 going to mascara alone.1 The eyelashes are part of ocular adnexa, and as eye care providers, we should be talking to our patients about their make-up habits. Mascara, like most cosmetic products, is not regulated by the US Food and Drug Administration. It can contain waxes, pigments, resins, and even talc. When mascara does not do what it is meant to do, many women seek some other means to grow their lashes longer, fuller, and thicker or add to their lashes to extend them. Vaseline (petroleum jelly; Unilever), lavender essential oil, coconut oil, talc powder, eyelash enhancing serums, lash extensions, and fake lashes are a few of the options available. A side effect of the glaucoma medication bimatoprost (Lumigan; Allergan) led to the FDA approval of this prostaglandin analogue as Latisse (bimatoprost 0.03%) in 2008. Since that time more than 5 million bottles have been sold, with the average price per bottle ranging from $100 to $120.2 COVER FOCUS LONG LASHES, BUT AT WHAT PRICE? A B Figure 1. Lashes shown at baseline (A) and after 16 weeks of Latisse use (B). JULY/AUGUST 2015 | ADVANCED OCULAR CARE 69 COVER FOCUS A B Figure 2. Right eye, no drops (A); left eye (B), patient shows side effects from chronic use of glaucoma drops. Note iris darkening, increased superior sulcus, decreased fat, and ptosis. OUTSIDE OF EYE CARE What may be surprising to many is that Latisse is often prescribed by individuals outside of the eye care profession without a preliminary eye evaluation. Who? Dermatologists, online websites run by primary care physicians and registered nurses, and beauticians at day spas. There are even reports of the drug being sold at health clubs. The danger of these practices lies in the lack of education that consumers are given at the time of their purchases. Even if Latisse results in 25% longer, 106% fuller, and 18% darker eyelashes,3 this change does not come without risks. These risks, although not life-threatening, can have a negative impact on eyelid appearance over time. A term has been coined for the cosmetic changes patients undergo from prolonged use of topical prostaglandin analogues: prostaglandin associated periorbitopathy.4,5 Signs of prostaglandin associated periorbitopathy include redness of the eyelid margin, orbital fat atrophy, superior sulcus deformity, higher lid crease, endophthalmos, increased pigmentation of the adnexa, increased pigmentation of the iris, lengthened eyelashes that can become misdirected, and growth of unwanted hair in areas exposed to the eye drops (Figure 2).5 Orbital fat atrophy causes the patient to have a deepset eye and some ptosis. It also can produce a condition known as tight orbit syndrome, in which the lid becomes very tight to the globe, making examination of the superior portions challenging.6 Increased sulcus deformity also causes a droopy appearance to the eyes. All of these side effects would be frowned upon by a consumer trying to enhance her beauty. When Latisse first became available, I wanted to include it in my practice so I could provide the much-needed 70 ADVANCED OCULAR CARE | JULY/AUGUST 2015 evaluation, application demonstration, and education of the potential risks to patients. Also, I am a woman and a consumer, and I was intrigued by this new application of an existing medication. I wanted to try it myself. WHO IS A CANDIDATE? Some women are not candidates for the drug; anyone with a history of uveitis, active ocular infection, history of macular edema, or allergy to any ingredients should avoid using Latisse. If a woman is a good candidate, the eye care provider should document hypotrichosis and provide a baseline examination with “before” pictures of the lids and adnexa. Baseline intraocular pressure should be measured, and the color of the iris should be documented. The baseline examination should also include evaluation for any underlying ocular surface disease, including aqueous or evaporative dry eye disease, allergy, and blepharitis. Demodex blepharitis is a common problem, with some studies showing increased incidence as early as the third decade of life.7 All prostaglandin analogues, including Latisse, are contraindicated for these patients due to the risk for increased mite growth.6 Epilation of a few lashes should be performed at the baseline evaluation to determine the presence of Demodex. PROPER TECHNIQUE If a patient is a good candidate and is willing to invest in this cosmetic treatment, the next step is to demonstrate proper technique of application. The patient should be instructed to use the application brush provided and apply the solution to the upper eyelid margin at the base of the lashes. The need to avoid overuse should be emphasized. Some women find waiting 4 to 6 weeks for results is just too long, and they may think that “more is better” and a way to achieve faster results. Really, however, overuse is a good way to increase unwanted side effects and even unwanted hair. Stray hair will grow on the cheek, for example, if Latisse is applied there. Patients should be educated that Latisse must be discontinued if they become pregnant or are nursing. This is also a good opportunity to talk to your patient about their makeup habits. You can educate them on the importance of removing their makeup every night and recommend products that work without harsh chemicals: eg, coconut oil as a natural makeup remover. Educate them to properly replace their makeup and to avoid sharing cosmetics with others. Promote the idea that good lid hygiene is the first step in achieving long, lush eyelashes. BACK TO BASELINE As for me, after a 6-month trial of Latisse I did have longer lashes, but I also had redness on my lid margins. I discontinued use before trying for my second child, and within 4 months my eyelashes were back to baseline. Some of my patients have had great success with this drug, but most, in the end, have discontinued it due to the long-term costs. n 1. Crooks R. Splurge vs. save: which beauty products are worth the extra cost? http://www.instyle.com/beauty/15-under-15-best-bargain-beautyproducts. Accessed July 13, 2015. 2. Latisse Frequently Asked Questions. www.Latisse.md. https://www. latisse.md/latisse-frequently-asked-questions. Accessed July 9, 2015. 3. Latisse [package insert]. Irvine, CA: Allergan Inc; 2008. 4. Tan J, Berke S. Latanoprost-induced prostaglandin-associated periorbitopathy. Optom Vis Sci. 2013;90(9):e245-247. 5. Pasquale LR. Prostaglandin associated periorbitopathy. Glaucoma Today. June 2011; 52-58. 6. Filippopoulos T, Paula JS, Torun N, et al. Periorbital changes associated with topical bimatoprost. Ophthal Plast Reconstr Surg. 2008;24:4:302-307. 7. Hom M. Treatment approach in addressing Demodex mites on lids. Optometry Times. October 2013. Leslie E. O’Dell, OD Director of the Dry Eye Center at Wheatlyn Eye Care, York, Pennsylvania n [email protected]; www.twitter.com/helpmydryeyes n Financial disclosure: none acknowledged n