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CLAE 943 No. of Pages 6

Contact Lens and Anterior Eye xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Contact Lens and Anterior Eye

journal homepage: www.elsevier.com/locate/clae

Effect of lipid-based dry eye supplements on the tear film in wearers of

eye cosmetics
Michael T.M. Wanga , Irene (Sung Hee) Choa,b , Soo Hee Junga,b , Jennifer P. Craiga,*
a
Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand
b
School of Optometry and Vision Science, New Zealand National Eye Centre, The University of Auckland, New Zealand

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: To compare the effects on tear film parameters and contamination in cosmetic eyeliner wearers,
Received 14 October 2016 after single application of two lipid-based dry eye treatments: a lipid-containing lubricant eye drop and a
Received in revised form 31 January 2017 phospholipid liposomal spray.
Accepted 2 March 2017
Methods: Fifty participants were enrolled in a prospective, randomised, paired-eye, investigator-masked
trial. Pencil eyeliner (Body Shop1 Crayon Eye Definer) was applied to the upper eyelid periocular skin of
Keywords: both eyes, anterior to the lash line. Baseline tear film quality was assessed fifteen minutes after eyeliner
Eye cosmetics
application. A lubricant drop (Systane1 Balance) was then applied to one eye (randomised), and
Dry eye
Tear film
liposomal spray (Tears Again1) to the contralateral eye. Tear film contamination, lipid layer grade, non-
Contamination invasive tear film break-up time and tear evaporation rate were evaluated fifteen minutes post-treatment
Lipid layer and compared to pre-treatment values.
Tear film stability Results: Pre-treatment measurements did not differ between eyes assigned to lubricant drop and
liposomal spray. Tear film contamination was observed in a greater proportion of eyes following both
treatments (both p < 0.05), with no significant difference between treatments (p = 0.41). Both treatments
improved lipid layer thickness (both p  0.01), but effected no significant change in non-invasive tear film
break-up time or tear evaporation rate (all p > 0.05). Changes in tear film parameters did not differ
between treatments (all p > 0.05).
Conclusions: Both the lipid-containing lubricant eye drop and phospholipid liposomal spray result in
clinically apparent tear film contamination in eyeliner cosmetic wearers. Although both treatments
effected an increase in lipid layer thickness, neither displayed clinical efficacy in improving tear film
stability.
© 2017 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

1. Introduction Due to their ease of application, pencil eyeliners, containing

Eye cosmetics are used extensively to accentuate and highlight
the eyes [1–5]. However, their use has been suggested to be
associated with dry eye development [6–9]. Migration of
periocular cosmetic products into the tear film and ocular surface
has been reported [1,4,10,11], although the exact mechanism is not
fully understood. Cosmetic product migration is thought to
destabilise the superficial tear film lipid layer [3,4,8,10], thereby
reducing tear film stability and increasing the rate of tear
evaporation [12–14]. The resulting evaporative dry eye symptoms
can adversely impact upon ocular comfort, vision and quality of life
[12].
* Corresponding author.
E-mail address: jp.craig@auckland.ac.nz (J.P. Craig).
waxes, oils and pigments, are a popular cosmetic product [15].
They are commonly applied along the lid margin or lash line, in
close proximity to the ocular surface [1,15]. The migration of
eyeliner particles has been suggested to alter the lipid content and
viscosity of the tear film, which may contribute towards reduced
stability [2,16].
Many individuals present to optometric practice with symp-
toms of ocular discomfort due to dry eye. Aetiologically, dry eye is a
complex disease, with the various components of the lacrimal
functional unit susceptible to disruption from a wide range of
factors [17]. Regardless of cause, affected individuals are observed
to progress to a common vicious cycle of tear film instability,
hyperosmolarity and inflammation, which, without intervention,
can lead to ocular surface damage [12]. Evaporative dry eye is the
most common dry eye subtype, arising from disturbances in tear
film or ocular surface quality, and frequently as a result of
meibomian gland dysfunction (MGD). Meibum inspissation and

http://dx.doi.org/10.1016/j.clae.2017.03.001
1367-0484/© 2017 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: M.T.M. Wang, et al., Effect of lipid-based dry eye supplements on the tear film in wearers of eye cosmetics,
Contact Lens & Anterior Eye (2017), http://dx.doi.org/10.1016/j.clae.2017.03.001
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gland blockage in MGD has an adverse impact on the tear lipid
layer, necessitating application of heat to encourage natural
meibum restoration, and/or supplementation with artificial lipid
products. Various treatments have been developed for evaporative
dry eye to supplement the tear film lipid layer [18–22]. Lipid-
containing lubricant eye drops contain an emulsion of mineral oils
and phospholipids [18,19,23], while liposomal sprays deliver
phospholipids across the lid margins [20–22].
Saline eye drop instillation has been reported to exacerbate the
migration of a periocular mixture of hydroxyethyl cellulose gel and
sodium fluorescein onto the ocular surface [10]. However, the
effects of evaporative dry eye treatments on tear film contamina-
tion in eye cosmetic wearers have not been studied. The aim of the
current study was to compare single application effects of a lipid-
containing lubricant eye drop and a liposomal spray, on tear film
parameters and contamination in eyeliner wearers, to inform
clinical recommendations for dry eye treatment in patients
concurrently wearing eye cosmetics. In order to investigate the
potential destabilising effects of tear film contamination [3,4,10],
slit lamp examination and clinical measurements of tear film
stability, evaporation and the lipid layer were conducted.
2. Methods
2.1. Subjects
This prospective, randomised, paired-eye, investigator-masked
trial followed the tenets of the Declaration of Helsinki, and was
approved by the University of Auckland Human Participants Ethics
Committee (UAHPEC-09631). Subjects were required to be female,
18 years or older, and non-contact lens wearers, with no history of
major systemic or ocular disease, no previous ocular surgery, no
topical or systemic medications affecting the eye, and no allergies
to eye cosmetics or topical eye medications. Eligible participants
were enrolled after providing written informed consent.
A total of 50 eligible participants was recruited, exceeding the
sample size requirement for the desired study power. The
designated outcome measure for determining sample size was
non-invasive tear film break-up time. Power calculations showed
that a minimum of 41 participants was required, to detect a
clinically significant difference of 5 s, in any of the four pairwise
comparisons, with 80% power (b = 0.2) at a two-sided statistical
significance level of 5% (a = 0.05). The SD of normal values being
estimated to be at 8 s [24]. Sample size estimates were determined
using a uniform non-parametric adjustment, with PASS 2002
(NCSS Statistical Software LLC, Utah, USA).
2.2. Materials
Participants were instructed not to apply facial cosmetic
products prior to the laboratory session. A fresh pencil eyeliner
(Crayon Eye Definer, The Body Shop1, New Zealand) was applied to
the periocular skin of the upper eyelid of both eyes of each
participant, anterior to the lash line. Pre-treatment clinical
assessment was conducted fifteen minutes following eyeliner
application.
2.3. Treatments
Random assignment of two lipid-based tear supplements to
either the left or right eye of participants, occurred such that one
eye was assigned a lipid-containing lubricant eye drop (Systane1
Balance, Alcon1, Texas, USA), and the contralateral eye a
phospholipid liposomal spray (Tears Again1, Optima Pharmazeu-
tische GmbH, Germany). The lubricant eye drop contains an
emulsion of phospholipids and mineral oils [18], while the primary
Please cite this article in press as: M.T.M. Wang, et al., Effect of lipid-based dry eye supplements on the tear film in wearers of eye cosmetics,
Contact Lens & Anterior Eye (2017), http://dx.doi.org/10.1016/j.clae.2017.03.001
active ingredient of the liposomal spray is phosphatidylcholine
[20]. Following pre-treatment clinical assessment, a single drop of
lubricant eye drop was applied to one eye, while the fellow eye
received a single liposomal spray onto closed eyelids from a
distance of 10 cm, according to the respective manufacturer's
instructions. A midline nose bridge septum was used to minimise
contamination of the other eye during spray application [25]. Post-
treatment clinical assessment was conducted fifteen minutes
following treatment application.
2.4. Measurements
The McMonnies Dry Eye Questionnaire and Ocular Surface
Disease Index (OSDI) questionnaires were administered to grade
the severity of dry eye symptoms at baseline.
The investigator conducting clinical assessments was masked
to treatment randomisation. Clinical assessments were performed
pre-treatment and post-treatment. Slit lamp examination was
used to identify any tear film contamination (appearing as dark
pigment particles), tear film debris, and lid margin foaming. The
lower tear meniscus height was determined from a high
magnification digital image, calibrated via graticule, by Image J
software (National Institutes of Health, Maryland, USA). Non-
invasive tear film break-up time and lipid layer grade were
evaluated with the Tearscope Plus (Keeler, UK), with and without
the fine grid insert, respectively. Non-invasive tear film break-up
time was recorded as the time taken, after a blink, for the grid
reflection to first show distortion, while the subject maintained
fixation and was requested to refrain from blinking. Three
consecutive break-up time measurements were averaged. Lipid
layer grading was based on the Guillon-Keeler grading system:
grade 1, open meshwork; grade 2, closed meshwork; grade 3, wave
or flow; grade 4, amorphous; grade 5, colored fringes. Grade 0 was
assigned to non-continuous layer due to non-visibility of lipid/
abnormal colored fringes [26]. Tear evaporation rate was measured
using a Vapometer (Delfin, Kuopio, Finland) with a swimming
goggle housing. Evaporation rates in the open and closed eye states
were recorded in order to factor out skin evaporation and allow
quantification of evaporation only from the tear film of the exposed
ocular surface.
To further classify dry eye status, sodium fluorescein and
lissamine green dyes were then applied, in turn, to the bulbar
conjunctiva in order to evaluate the localized corneal and
conjunctival areas of epithelial dessciation. The staining was
recorded using the modified Oxford grading scheme [27], where
the nasal and temporal conjunctiva were each divided into three
areas and the cornea into five areas. Staining was graded from 0 to
5 according to the level of confluence in each area, and summed to
provide a maximum score of 55. Infrared meibography was
performed using a meibographer (SDZ Ltd, Auckland, NZ), with the
upper and lower eyelids everted in turn [28]. From the captured
image, visible meibomian glands were outlined and the relative
area of meibomian gland dropout calculated using Image J
software. Percentage dropout was calculated by dividing the area
with no visible glands by the entire conjunctival area [29,30].
2.5. Statistics
Statistical analyses were performed using Graph Pad Prism
version 6.02 (http://www.graphpad.com). Comparison of contin-
uous variables (tear meniscus height, tear evaporation rate)
between and within treatment groups were performed using
multiplicity adjusted Sidak’s tests within a repeated measures
analysis of variance model, where normal distribution had been
confirmed by the Kolmogorov-Smirnov test (p > 0.05). Non-
normally distributed measures (non-invasive tear film break-up
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time) were logarithmically transformed before analysis. Ordinal
data (lipid layer grade) and categorical data (tear film contamina-
tion, tear film debris, lid margin foaming) were converted to rank
values prior to undergoing multiplicity adjusted non-parametric
analysis. Statistical correlation between the two dry eye symp-
tomatology questionnaires was tested using Spearman's rank
correlation coefficient. All tests were two-tailed and p < 0.05 was
considered significant. All continuous data are presented as
mean  SD, ordinal data as median (95% CI), and categorical data
as number of participants (% of participants), unless otherwise
stated.
3. Results
The mean age  SD of the 50 female participants was 27  10
years (range, 18 to 66 years). Baseline characteristics, pre-
treatment and post-treatment clinical assessments are listed in
Table 1. There were no statistically significant differences in
baseline characteristics and pre-treatment clinical assessments
between the treatment groups (all p > 0.05).
3.1. Classification
A majority of participants had McMonnies Dry Eye Question-
naire scores of <14.5 (86%), and OSDI scores of <12 (58%). The two
dry eye symptomatology questionnaires were significantly corre-
lated (Spearman’s rho = 0.70, p < 0.001). Baseline ocular surface
staining and meibomian gland dropout were minimal in both
treatment groups.
3.2. Slit lamp examination
Although there were no reports of adverse effects on periocular
cosmesis through smudging or tearing, following the application of
both lipid-based tear supplements, tear film contamination was
observed in a greater proportion of eyes following application of
both lubricant drop (p = 0.01, Fig. 1) and liposomal spray (p = 0.02),
than at baseline, although no significant difference was detected
between groups (p = 0.61). There were no significant changes in
tear film debris or lid margin foaming following both treatments
(all p > 0.05), and the two groups did not differ significantly (all
p > 0.05).
3.3. Tear film lipid layer grade
Tear film lipid layer grade was significantly greater following
treatment with both the lubricant drop (p = 0.009, Fig. 2) and
liposomal spray (p = 0.01). No significant differences were ob-
served in post-treatment lipid layer grade between groups
(p = 0.56).
Post hoc subgroup analysis showed significant improvements
in eyes with a pre-treatment lipid layer grade of 2 or less, following
both the lubricant drop (p = 0.03, Table 2) and liposomal spray
(p = 0.04), although post-treatment measurements did not differ

Table 1
Baseline characteristics, pre-treatment and post-treatment clinical assessments of the eyes of subjects randomised to lipid-containing lubricant eye drop and phospholipid
liposomal spray. Data are presented as mean  SD, median (95% CI), or the number of subjects (% of subjects). Asterisks denote statistically significant differences (p < 0.05).

Lubricant Drop Liposomal Spray p

(n = 50) (n = 50)
Baseline characteristics
Age (years) 27  10
McMonnies Dry Eye Questionnaire score 8.6  6.0
OSDI score 19.2  14.6
Sodium fluorescein staining 5.0  4.3 4.7  3.9 0.72
Lissamine green staining 1.4  2.4 1.2  2.9 0.65
Meibomian gland dropout (%) 1.8  1.5 1.9  1.5 0.87

Slit lamp examination

Tear film contamination Pre-treatment 5 (10%) 6 (12%) >0.99
Post-treatment 19 (38%) 15 (30%) 0.61
p 0.01* 0.02*
Difference +14 (+28%) +9 (+18%) 0.41
Tear film debris Pre-treatment 8 (16%) 7 (14%) >0.99
Post-treatment 12 (24%) 13 (26%) >0.99
p 0.51 0.26
Difference +4 (+8%) +6 (+12%) 0.81
Lid margin foaming Pre-treatment 7 (14%) 7 (14%) >0.99
Post-treatment 5 (10%) 4 (8%) >0.99
p 0.81 0.58
Difference 2 ( 4%) 3 ( 6%) > 0.99

Tear film parameters

Lipid layer grade Pre-treatment 3 (3 3) 3 (3 3) 0.82
Post-treatment 3 (3–4) 3 (3–4) 0.56
p 0.009* 0.01*
Tear meniscus height (mm) Pre-treatment 0.30  0.09 0.30  0.10 0.98
Post-treatment 0.34  0.11 0.32  0.11 0.33
p 0.04* 0.19
Difference +0.04  0.11 +0.02  0.11 0.31
Noninvasive tear film break-up time (s) Pre-treatment 9.8  4.3 9.8  4.4 0.95
Post-treatment 9.5  4.7 9.4  4.1 0.58
P 0.63 0.46
Difference 0.3  3.6 0.4  3.3 0.61
Tear evaporation rate (g/m2h) Pre-treatment 119  55 110  54 0.36
Post-treatment 103  48 110  56 0.42
p 0.08 0.99
Difference 16  48 0  62 0.23

Please cite this article in press as: M.T.M. Wang, et al., Effect of lipid-based dry eye supplements on the tear film in wearers of eye cosmetics,
Contact Lens & Anterior Eye (2017), http://dx.doi.org/10.1016/j.clae.2017.03.001
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p = 0.02* 3.4. Tear meniscus height

p = 0.01* Tear meniscus height increased following lubricant drop

application (p = 0.04), but not following liposomal spray applica-
p > 0.99 p = 0.61
tion (p = 0.19). However, the change in tear meniscus height did not
60 vary significantly between groups post-treatment (p = 0.31).

3.5. Tear film stability

50
% of Eyes with Contamination

Both treatments did not effect significant change in non-

invasive tear film break-up time (both p > 0.05), and no significant
40
differences in break-up time changes were detected between
groups (p = 0.61).
30
3.6. Tear evaporation rate

20 Tear evaporation rate did not change following either treatment

(both p > 0.05), and no significant differences were observed
10
between groups (p = 0.23).

4. Discussion
0
Lubricant Drop Liposomal Spray Lubricant Drop Liposomal Spray
The findings demonstrate that single application of both lipid
based tear supplements in participants wearing eyeliner did not
Pre-treatment Post-treatment
adversely affect periocular cosmesis, although slit lamp examina-
Fig. 1. Pre-treatment and post-treatment tear film contamination in eyes tion revealed tear film contamination in a greater proportion of
randomised to lipid-containing lubricant eye drop and phospholipid liposomal eyes following both treatments. Although both temporal and
spray. Each bar represents the percentage of eyes with tear film contamination on treatment effects are acknowledged to contribute, these results
slit lamp examination. Error bars represent the 95% confidence interval. Asterisks
would suggest that both delivery modalities may potentially
denote statistically significant differences (p < 0.05).
facilitate the migration of eyeliner particles into the tear film.
Previous studies have demonstrated the migration of liposomes
p = 0.01 *
across the lid margin [18,20–22]. The increased tear film
contamination following phospholipid liposomal spray may
p = 0.009 *
potentially be due to the interactions between the liposomes
p = 0.82 p = 0.56 delivered and the eyeliner particles. Although the mechanism in
which liposomes and particles migrate towards the tear film is not
100
Key: fully understood, it has been hypothesised that the action of the
Grade 5 muscles of Riolan may enhance such movement [1,31,32]. The
% of Eyes with Lipid Layer Grade

Grade 4 vertically aligned fibres of the muscles of Riolan lie immediately

75
Grade 3
subjacent to the eyelid skin. Their function is not fully understood,
but they may potentially be involved in keeping the eyelid margin
Grade 2
in close approximation to the globe, expressing meibomian
Grade 1
secretions, and maintaining eyelash orientation [31,32]. They are
50
Grade 0
also thought to create tiny vertical movements of the eyelid skin,
thereby promoting the migration of periocular liposomes and
particles towards the tear film and ocular surface [1,31].
25 The results of the lipid-containing lubricant eye drop group in
the current study, is in agreement with an earlier report, which
describes increased migration of the more hydrophilic mixture of
0
hydroxyethyl cellulose gel and sodium fluorescein across the lid
Lubricant drop Liposomal spray Lubricant drop Liposomal spray margin, following the application of saline eye drops [10]. It has
been suggested that the transfer of periocular particles onto the
Pre-treatment Post-treatment
ocular surface may be encouraged by the mechanism of the eyelids
Fig. 2. Pre-treatment and post-treatment tear film lipid layer grade distribution in during blinking. Saline eye drop instillation may induce excessive
eyes randomised to lipid-containing lubricant eye drop and phospholipid liposomal and forceful blinking, due to associated corneal sensation and fluid
spray. Bars represent percentage of eyes within each lipid layer grade. Density of overflow. This process may also to apply to the increased migration
shading corresponds to lipid layer grade. Asterisks denote statistically significant
of eyeliner particles with lubricant eye drop instillation in the
differences (p < 0.05).
current study. However, the exact mechanism in which blinking
enhances the transfer of periocular particles across the lid margin
is contended, and the recent identification of the “overblink”
phenomena [33], suggests that migration is unlikely to be
facilitated by direct mechanical apposition of the eyelids during
blinking [1].
between the two lipid supplements (p = 0.81). Both treatments did
Statistically significant improvements in the tear film lipid layer
not effect significant change in eyes with a pre-treatment lipid
grade were observed following single application of both the
layer grade of 3 or more (both p > 0.05).
lubricant drop and the liposomal spray. Post hoc subgroup analysis

Please cite this article in press as: M.T.M. Wang, et al., Effect of lipid-based dry eye supplements on the tear film in wearers of eye cosmetics,
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Table 2
Post hoc subgroup analysis of pre-treatment and post-treatment tear film parameters of the eyes of subjects randomised to lipid-containing lubricant eye drop and
phospholipid liposomal spray, according to pre-treatment lipid layer grade. Data are presented as median (95% CI) or mean  SD. Asterisks denote statistically significant
differences (p < 0.05).

Pre-treatment lipid layer grade 2 Pre-treatment lipid layer grade 3

Lubricant Drop (n = 10) Liposomal Spray p Lubricant Drop Liposomal Spray p

(n = 10) (n = 40) (n = 40)
Lipid layer grade Pre-treatment 2 (0 2) 2 (0 2) >0.99 3 (3 3) 3 (3 3) 0.73
Post-treatment 3 (0 3) 3 (0 3) 0.81 3 (3–4) 3 (3–4) 0.86
p 0.03* 0.04* 0.21 0.25
Tear meniscus height (mm) Pre-treatment 0.33  0.14 0.34  0.13 0.68 0.29  0.08 0.29  0.09 0.99
Post-treatment 0.39  0.17 0.36  0.16 0.29 0.33  0.09 0.32  0.09 0.45
p 0.37 0.83 0.04* 0.14
Difference +0.06  0.19 +0.02  0.15 0.46 +0.04  0.09 +0.03  0.10 0.68
Noninvasive tear film break-up time (s) Pre-treatment 9.3  4.7 8.4  3.4 0.39 9.9  4.3 10.1  4.5 0.51
Post-treatment 8.1  2.5 8.6  3.5 0.42 9.8  5.1 9.6  4.2 0.72
p 0.52 0.67 0.31 0.19
Difference 1.2  3.1 0.2  2.3 0.21 0.1  3.7 0.5  3.5 0.62
Tear evaporation rate (g/m2h) Pre-treatment 119  61 129  71 0.74 119  54 106  49 0.14
Post-treatment 111  55 91  58 0.44 101  47 115  55 0.17
p 0.84 0.33 0.07 0.39
Difference 8  58 38  61 0.34 17  51 9  59 0.11

demonstrated that these improvements were limited to eyes with
a pre-treatment lipid layer grade of less than 3. These findings are
consistent with previous research, which report increased lipid
layer thickness following single application of both treatments
[20,23]. The active ingredients of both treatments include polar
phospholipid surfactants, which provide an interface for the
spreading of non-polar lipids over the aqueous-mucin phase
[18,20,34,35]. In this way, the artificial supplementation of polar
phospholipids may encourage the formation of a stable and
continuous lipid layer. However, given the increased transfer of
periocular particles across the lid margin after treatment applica-
tion, the contribution of eyeliner waxes and oils to the increased
lipid layer thickness cannot be excluded. A previous study
describes an increase in lipid layer grade following seven days
of eyeliner application albeit in closer proximity to the tear film, at
the mucocutaneous junction, although this was not observed
following the first day of application [16].
Interestingly, the improvements in lipid layer thickness
following application of both treatments were not associated with
any changes in the tear film stability. This contrasted with previous
studies investigating the effects of both dry eye treatments, which
describe improved tear film stability [20,23]. There were no
significant changes in tear evaporation rate following single
application of either supplement. The increase in tear meniscus
height following instillation of the lubricant eye drop was less than
0.05 mm, and therefore of limited clinical significance, with levels
remaining within physiological range. The supplementation of
polar phospholipids by both treatments should theoretically
promote the formation of a continuous lipid layer, which inhibits
tear film evaporation and increases tear film stability
[13,18,20,34,35]. However, this effect may be potentially hindered
by the increased migration of eyeliner particles into the tear film.
The contamination of the tear film may disrupt the superficial lipid
layer, which would be expected to increase tear evaporation and
reduce tear film stability [2,4,11,16]. It is possible that the
competing effects of lipid supplementation were negated by
increased tear film contamination, resulting in the modest changes
in lipid thickness and the lack of significant change in tear film
stability following single application of both dry eye treatments.
Of note, single application of either a lipid-containing lubricant
eye drop or a phospholipid liposomal spray in eyeliner cosmetic
wearers did not affect cosmesis through smudging or tearing.
However, visibly increased tear film contamination under slit lamp
examination was observed, relative to baseline, following single
application of both lipid-based supplements, with no significant
differences noted between delivery modality. This has clinical
implications, given the high prevalence of evaporative dry eye, and
the widespread use of eye cosmetic products. Although both
supplements effected immediate improvements in tear film lipid
layer grade, their potential clinical efficacy in improving tear film
stability appears to be compromised when applied concurrently
with eye cosmetic products. Future studies with longer follow-up
periods are required to evaluate potential delayed and cumulative
effects of lipid-based supplements in eye cosmetic wearers.
Acknowledgements
The authors have no conflicts of interest to declare. This
research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors. The researchers
are grateful to ‘The Body Shop1, NZ’ for subsidising the cost of the
eyeliners used in this study and to Alcon1 (NZ) and Optima
Pharmaceutische1 (Germany) for donating the tear supplements.
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