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Sources in Time

Ocular in Ancient Times

JUAN MURUBE, MD, PHD

lthough cosmetics, from no graphic written quotations with the proportions, the mixture had A Greek kósmesis (adorn), now regard to cosmetics. (The old terms various color tones and consistencies. refers to external products do not correspond to present termi- The black paste or mesdemet was used used to beautify the skin, hair, eye, or nology. For instance, antimonium to give shadow color to the upper and other parts of the body, cosmesis was was introduced by alchemists about lower lids, and to extend the outline of not the first objective of primitive eye four centuries ago, referring to the the inner and outer lid rims and the painting. The first aim of body painting Latin stibium, hence, the symbol Sb (Figure 1). After the fourth in primitive cultures may have been to for antimony.) dynasty, it was common to extend the protect people from evil spirits, which A few centuries later, hieroglyphic eyebrows and the outer corner of the could enter their body through vulner- and phonetic script were developed lids to the temple. The black paste was able openings, such as the eyes. The in ancient Egypt, and from then on, probably different for rich and poor second aim was for medical purposes, abundant information about eye medi- people, as the antimony-based pastes to treat visible or nonvisible pathologies cines and cosmetics were recorded. were more expensive than the lead- in the eye (such as conjunctivitis, hor- The pharmacopoeia of Pharaonic based ones. deolum, corneal ulcer, white cataracts, Egypt was rich in liquid and pasty Most of these products came from loss of vision) or elsewhere in the ocular applications obtained from the Nile valley, Sinai peninsula and body. Lastly, cosmetics were used to botanical sources (eg, henna, myrrh, Mediterranean-Jordan strip, but some enhance the association of the eyes incense, cedar or sycamore sawdust, were imported from Arabia and other with youth, beauty, and social power. gum arabic, burnt almonds, olive oil); parts of south , including mesde- In some cases, two or three objectives from animals (eg, fat, honey, mamma- met of antimony sulfide, which did were combined. Rupestrian paintings lian, lizard or bat blood, women’sor not exist in Egypt. In ancient Egypt, and stone engravings provide evidence animal milk, liver pastes, turtle brain); the principal markets for cosmetics that were painted to give them or from minerals (eg, hematites [iron and other merchandise were Babylon an appearance of youth or power in oxide], galena [lead ore, plumbic and Athens.1 The liquid and pasty prehistoric paleolytic and neolytic sulfate], cerussite [plumbic carbonate collyria were used for religious, times. Historic times began with the and lead hydrate], stibnite [antimony medical, or cosmetic purposes. gradual development of script. sulphide], lapis lazuli [silicate of About 8 millennia ago, the Sume- aluminium mixed with sulfate of USES OF COSMETIC SUBSTANCES rians of Mesopotamia introduced agri- calcium and soda, and frequently with Religious Use culture and cattle farming, followed iron pyrites], chrysocolla [copper ore During life, mystic protection of about 2 millennia later by picto- or copper hydrosilicate, with silica], the gods against diseases and accidents graphic and syllabic writings. Sume- malachite [copper carbonate], copper was always present. It was believed rians and Babylonians left little sulfate, copper oxide, mercury oxide, that some body paintings had magical information about ocular pastes and zinc oxide, and potassium nitrate. and protective power. They were used cosmetics. The Assyrian cuneiform The most frequently used substance in everyday life or in religious rituals tablet of the physician Nabu-le’u cites was the “black paste” for the eyes, called and were applied to males and females antimony, copper, zinc oxide, iron mesdemet and mainly composed of of all ages. Even after a person’s death, oxide, arsenic, and sea salt for the plumbic sulfate or antimony sulfide. different parts of the body were treatment of the eyes, but there are Other cosmetics for the eye and other painted, such as the eyes, in order to parts of the body were green collyrium present a look of respect and submis- Juan Murube, MD, PhD, is Professor Emeritus, or ouadjou that contained copper sion in the world of the gods and University of Alcalá, Madrid, Spain. carbonate or hydrosilicate. Also used spirits, and perhaps also to enhance were ground green malachite, gray the corpse’s appearance for the © 2013 Elsevier Inc. All rights reserved. The galena, white cerussite, reddish copper, mourners attending the burial ritual. Ocular Surface ISSN: 1542-0124. Murube J. blue-green chrysocolla, and ochre ash. The British Museum preserves a box Ocular cosmetics in ancient times. Usually they were mixed with oil or for cosmetic cleaning that belonged to 2013;11(1):2-7. fat. When combined, depending on the spouse of the scribe Ani, in the 18th

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Cosmetic painting of the lids and is considered to have been first practiced by adult women, and later on by pubescent girls (until recently, most females married when pubescent). These young girls perhaps used eye painting to copy the ways of adult ladies, as a subconscious or conscious manifestation of their matu- rity, elegance, and/or social state. The verb “to make up the eyes” was sedje- mir, which also meant “to speak with the eyes” or “to express with the eyes.” The use of cosmetics by men was less frequent, maybe because their manifestation of masculinity was mainly based in their physical strength, authority, and power. Moreover, lid cosmetics had perhaps become a symbol of femininity, and thus their use would not have made men attractive to women or respected by society. However, men did use lid makeup (Figure 2), although infrequently, and sometimes they dyed the beard, mustache, hair, eyebrows and eyelashes. In the Ancient Empire the most frequent color used was the green udyu, a and paste made with crushed malachite stone. However, Figure 1. Queen Nefertiti (circa *1390-þ1360 BCE). The eyebrows, lid rims and eyelashes are after the IVth dynasty, black mesdemet painted, and the line of the lateral lid corner is extended to the fronto-malar orbital bones. became the most commonly used. Other commonly used body and eye cosmetics were white cerussite powder dynasty (1550-1295 BCE). It contains papyrus cites more than 50 times the use and the blue of lapislazuli. some wooden tubes with paste “for of mesdemet on the eyebrows, lid Tattooing of skin on the forehead, smearing the eyes during the periods of surface, and eyelashes, not only to eyelids, or hands was also frequent. It the Nile river swelling” (in those times make them more visible and apparently was usually done with henna. Henna is the real causes of the Nile swelling bigger, but also to maintain their health a vegetable dye obtained from Lawsonia were a mystery and were considered to – to treat and eliminate the ”blood inermis or Lawsonia alba, whose leaves, be divine). Other tubes contained paste around the eye,” to treat “sudden eye when crushed and dried, produce for the dry periods and for protection pain,” and to kill lice and nits.4-6 It could a reddish powder. When the powder against wind-borne sand. be used alone or mixed with other was mixed with water, it formed a paste substances, such as wood powder, used to paint hands, nails, grey hair, and Medical Use onion, or, in severe ocular external eyelids. Its dark-red color on the applied Conjunctivitis, including trachoma edemas, with “the milk of a woman cutaneous surfaces was nonperma- and other forms, and were who has just borne a boy.”2 nent.8 Frequently, aromatic compo- very common in ancient cultures, such Some modern pharmacologic nents, such as fir resin, myrtha, as Pharaonic Egypt. The Ebers papyrus,2 studies do not verify a clinical calamus, and many others, were added circa 1550 BCE, states that many people improvement of the eyes with to the cosmetic. “can not produce eyelashes in their conjunctivitis, blepharitis or dermatitis Aside from its cosmetic purpose, the lids,”3 which suggests that blepharitis that were treated with mesdemet.7 painting of the eyes played a preventive was common. Already in the Ancient and protective role in eye pathologies, Empire (z 2.650-2.150 BCE), the Cosmetic Use sometimes contributing to improve- most commonly used pastes for medical Cosmetics were very common in ment of vision and preservation of eye treatments or for cosmesis were ancient Egypt and were used by men health. In the Old Hebrew civilization, the “black pastes for the eye.” The Ebers and women, whether rich or poor. the Bible several times uses the term

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yellow color, which, when mixed with water, becomes bright red. In classic Greece, the term kolly- rion referred to pastes and solutions with various components and combi- nations to be used as medications. Dioscorides cited ocular unguents for medical use, such as stibnite, vitriol (salts of sulfuric acid), and lapis laz- uli.17 Some of them were also used to embellish the eyes. So, Dioscorides wrote that “a good paste of stibnite is a cosmetic,” and it had the popular names of “enlarger of the eyes” and “embellisher of the women.”18 The classic Roman culture took the Greek term kollyrion and modified it Figure 2. Golden mask that covered the face of the mummy of the Pharaoh Tutankhamen (circa to the Latin collyrium. The term applied 1346-1327 BCE), made with sheets of gold painted with carnelian and lapislazuli. The lines of the lid to various balsams and pastes for rims and the eyebrows are extended over the temples. medical uses in various parts of the body. Collyris was an ornament in the form of a round flat tortilla that women phukh for a black paste for medical use, centuries ago when the Portuguese used on the head, first as a medical frequently in the eyes.9 In the Babylo- discovered a marine route around the plaster and later as a cosmetic on the nian Talmud10 (IV-VI century CE), Cape of Good Hope in South Africa. forehead.19 The chemical composition the terms kolron and kechol are cited Ayurvedic cosmetics were made of the substance was very different for several times to refer to face pastes or with various substances, such as stib- each use. Plinius the Elder wrote that eye creams, whose use was curative or nite, lead, mustard oil, almond oil, or many women used stibium, a paste for embellishment of the lids.9,11 Rabbi lamp soot. Eyes painted with these collyrium of antimony that also con- Johanan and Rabbi Jose stated that anti- substances were healthier and looked tained silver and other components, to mony, “the powder of stibium stops the bigger, brighter, and more beautiful. blacken their eyelashes, lids, and tears and promotes growth of Surma was the name given to the black eyebrows.20 eyelashes.”10,12,13 paste for the eyes ( in Arabic Romans frequently added perfumes In the Indus valley, the first infor- culture). Henna, locally known as or other physical embellishers to mation about the historic use of ocular mehndi, was introduced in the Indus cosmetic collyria, eg, the collyrium of cosmetics is based on pictures and valley between the IV and VI centuries Atropa belladonna. This collyrium had writings. CE.14 Uptan, made from triturated been used in Ancient Egypt as Over millennia BCE, there was nuts and flowers, was used to beautify a narcotic, and in Syria to relieve Indian, Persian, and Assyrian trade lids and other skin surfaces. Other melancholy. Romans used it to provoke with Southwest Asia and the East cosmetics used for this purpose were a moderate pupillary mydriasis, which Mediterranean (involving Sumerians butter and oil pastes made from saffron. lasted for some days and was consid- of Mesopotamia, Ancient Egypt, Indus The glabella, ie, the space between ered beautiful.20-23 valley, classic Greece, classic Rome, eyebrows, receives its name from Latin In , the Chinese culture and Chinese, Japanese, and Arab glabella, diminutive of glaber, meaning had an important interaction with the cultures). This commerce between without hairs. The glabella is an Afro-Eurasian countries through the India and the Mediterranean countries important area, because in humans, silk routes. The silk routes influenced increased with discovery by the Phoe- its appearance expresses attention, not only trade, but also cosmetics, nicians of cañailla purple dye, a red fury, peace, and other states of mind. technology, religion, philosophy, and and blue dye extracted from the The Vedic religion said that this area military expansion, not only with molluscan Murex brandaris, and with is “the third eye,” which “sees and but also among the countries the “silk routes.” The fabric of silk- understands” intuitive concepts, gives on the routes.24,25 worms was invented by the Chinese. clairvoyance, and maintains youthful- In ancient China, the model of The export of silk to middle Asia, ness and mental health.15,16 Even cosmesis was white face, dark eyebrows, East Asia, and Mediterranean coun- now, many women of the Hindu and floral glitter gold. The white tries was so important, that this route cultures paint a red circle on it to cosmetic was made with rice powder, took the name of “silk route(s).” This beautify the face. This pigment is and trade and pilgrimage extended its trade began to diminish about five ground turmeric (kurkum) of intense use to Western countries. The model

4 THE OCULAR SURFACE / JANUARY 2013, VOL. 11 NO. 1 / www.theocularsurface.com SOURCES IN TIME / Murube of beauty for Japanese women was a face and the Mohammedan influence. Islam discussed hygiene and medicines for and lids whitened with rice powder, and introduced new codes of behavior for the eye, applying the name Akal to the the lid edges and eyebrows colored men and women, such as public segre- dry collyria.28,29 orange-yellow with crushed safflower gation of the sexes and female veiling. The use of eye cosmetics increased petals.26 This is the model copied by The use of the veil increased the impor- even in Egypt. For instance, the Venetian the modern geishas. tance of cosmetics for the eyes, glabella Prospero Alpinus, who lived in Egypt In the Buddhist religion, which and hands, as these were the most between 1580 and 1584, wrote that all began in the V Century BCE in visible areas (Figure 4). the Egyptian women had small boxes and spread mainly to East Asia, the The Arab culture maintained many with cosmetics, such as incense and oil, face of Gautama Buddha is sometimes of the cosmetics of ancient Egypt and of or with kohl to blacken the lid rims.30 represented with the eyebrows joined other Semitic and Aryan countries in The great influence of the Arab in the glabella (Figure 3). their domain, using compounds of anti- culture in medieval Europe did not In the VII and VIII centuries CE, the mony, lead, or henna. The use of kohl popularize the use of kohl in the Chris- Arabs conquered to the west the Medi- spread in the new Arabic cultures. Al- tian countries; the Christian church terranean North-African lands and the Qoatí of Toledo (XII century CE) leaders considered it sinful to use European Iberian peninsula, and to explained how to prepare the mineral makeup, and this discouraged its use the east, the Syrian, Mesopotamian, stibium by washing, burning and moist- among the elegant ladies. However, its and Persian countries. They respected ening it for ocular application.27 He use increased later, especially in Renais- the use of the cosmetic pastes used by cited other pastes for the eyelashes: sance Italy and in the European “Illus- the Coptic and other conquered coun- “Collyrium of a wise man for the tration” (the period of cultural change tries, and maintained and increased growing of the eyelashes” (quotation introduced with the French Revolution their use in Egypt and other societies 144); “Collyrium of Ibn Tlaws to make and death of Louis XVI [1793]). with Mohammedan culture. The the eyelashes grow” (quotation 145); and cosmetics, which already and “Description of a medicament to TOXICITY OF COSMETIC existed in many cultures, became more maintain the eyelashes and eyebrows” SUBSTANCES widespread with the Arab expansion (quotation 147). Al-Gafiqi of Cordoba Kohl intoxication through the use of ocular cosmetics with antimony is practically nonexistent. Intoxication due to oral ingestion of antimony is rare, and when it occurs, it is mani- fested by vomiting, diarrhea, migraine, cardiac arrhythmia, and hemorrhage. However, intoxication by lead (intoxi- cation saturnine) is the most frequent mineral intoxication in humans, and when the amount of lead exceeds the normal values of 11 mg/dL (5.31 mmol/L), polyneuropathy, he- adache, psychological inhibition, myalgia, and renal insufficiency can occur. Lead intoxication affects chil- dren more than adults, and cases of death produced by the abusive use of lead-containing kohl have been described. Some surfocular cosmetics contain up to 60-80% lead.31 Cases of lead intoxication in patients abusing the lid application of pastes with an excess of lead have been reported.32,33 Lead intoxication can also be produced by causes not related to lead kohl, such as the use of old lead pipe lines, lead mining, industrial use, and use of lead in gasoline, wall paints, etc. Most Figure 3. Buddha represented with the glabella covered by the eyebrows. (Mahamuni Buddha, developed countries now have strict Mandalay, Myanmar. Courtesy of Yashi Wong. Available at http://commons.wikimedia.org/wiki/File: laws governing the use and control of Buddha_00007.JPG. Licensed under the GNU Free Documentation License.) these products.

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and hands, which remained black for some days. Currently, confusion still exists if the term kohl is applied to a cosmetic or medical black substance to be applied to the lids, even when this product is not made of stibnite (anti- mony sulfur), but galena (native lead sulfide), manganese, or other ingredi- ents. Consequently, any kohl paste must detail its composition as a guar- antee of safety.

TERMINOLOGY RELATED TO KOHL Another word derived from the term kohl, whose meaning has evolved Figure 4. Lady using an Andalusian veiling. Eyelids, temple, glabella and lower forehead have to use with other chemical products, is been painted with henna. Upper lid of the right eye is painted with kohl. alcohol. Alcohol perhaps has the same etymology as kohl. According to the Oxford and Webster dictionaries,38,39 CHEMICAL COMPOSITION OF KOHL name kohl. Only one was pure antimony alcohol comes from the finely pulver- With respect to etymology, the sulfide, and the others added lead, lead ized antimony used to darken the term kohl is thought to derive from sulfide, zinc oxide, copper, and vegetable eyelids, from Arabic kohl, kuhl, or the Semitic term ákhal, meaning black. matter in different proportions.1 kuhul, with the addition of the Arabic Later, this term evolved to many dia- In more recent studies, Al-Hazzaa definite article al-. The Andalusian lectal variants, such as kohol, khol, et al analyzed samples of kohl. They Arabic al-kuhl or al-kuhúl term passed kúhl, kohal, kajal, kéhela, which refer found antimony in only one of them, to the Old Spanish alcohol, and then to to the color of the powder or paste.34 and in a small proportion of 7.8%, the the Middle Latin of books, and finally For instance, a dark-colored powder rest being mainly lead.35 In a study about to the verbal European languages. recently sold in Egypt with the name the composition of kohl, lead content The Swiss alchemist and physician of kohl was made of crushed stibnite, was 53% in a Saudi Arabian sample36 Paracelsus (1493-1541) had mentioned burnt almonds, lead, oxidized copper, and 79.5% in an Israeli sample.37 in the first half of the XVI century the ochre, ash, malachite, and chrysocolla. However, kohl may have other term alcohol in the Low Latin of the With respect to chemical composi- fundamental components. In the European scientific books to mean tion, the first verified meaning of the second half of the XX century, when the spirit of the wine.40 Currently, the Semitic Arabic term kohl was applied the occidental Sahara was a Spanish term alcohol means not only the to a cosmetic black paste, usually of province, most of the native Saharauis ethylic alcohol obtained by distillation stibnite (antimony sulfur), to paint painted their lids with kéhela (Saharan of wine, but also other organic the eyelids. The Prophet Muhammad dialectal term derived from kohl).34 compounds with the oxhydril group advised the use of ethmid, a mountain This kéhela, analyzed in the University (HO-).41 Nevertheless, some Arab mineral stone, today known as a variety of the Canary Islands was identified as scholars say that “the famous Webster of stibnite, which consists mainly of powder of manganese bioxide (pyrolu- dictionary is wrong, because, how antimony trisulfide, is rather inert, site, MnO2), mixed with powder of could such a highly irritant and corro- and does not irritate the . iron oxide and quartz crystals.* It was sive substance have anything to do The composition of kohl has varied. mixed with ostrich grease, forming with a commonly used cosmetic? The main component of kohl seems to a paste. This paste was applied to the Alcohol will burn the eye,” and it was have been antimony salts and/or lead conjunctiva in cases of trachoma or suggested that alcohol comes from salts, as deduced from the chemical other types of conjunctivitis or lid irri- the Arabic al-ghol (the genius or spirit studies of cosmetic residues found in tation. It was also used by women as that can alter the mind). a millenary Egyptian flask of mesdemet. a cosmetic to paint the rims and ante- There may be two different reasons Recently, there have been more and rior surface of the lids, eyebrows, lips for the differences between the substan- more products that maintain the name tive name kohl and the chemical kohl, but have different composition, substances that actually compound it. usually with more lead components. At *Juan Murube was Chief of the Ophthal- First, the term kohl always signified the the beginning of the XX century, mology Department of the Hospital of cosmetic pastes that give a dark or black El-Aaiun (Sahara) and Professor of Hirschberg analyzed 10 different prod- Ophthalmology at the University of Canary color to the eyelids or other skin, ucts used to clarify vision, sold with the Islands between 1971 and 1978. independently of their chemical

6 THE OCULAR SURFACE / JANUARY 2013, VOL. 11 NO. 1 / www.theocularsurface.com SOURCES IN TIME / Murube composition. Second, kohl was initially 7. Estes JW. The medical skills of ancient Egypt. 24. Prevas J. Envy of the gods: Alexander the the antimony paste, but for commercial ed 2. Canton MA, Science History Publica- Great’s ill-fated journey across Asia. Cam- reasons, the quantity of the original anti- tion, 1993 bridge MA, De Capo Press, 2004 mony was reduced, or even eliminated. 8. Dron P, Lafourcade MP, Leprince F, et al. 25. Bergreen L. Marco Polo: from Venice to The new substances with other more Allergies associated with body piercing and Xanadu. London, Quercus, 2007 tattoos: a report of the Allergy Vigilance 26. Gallagher J. Geisha: A unique world of tradi- economical mineral salts substituted fi Network. Eur Ann Allergy Clin Immunol tion, elegance, and art. London, PRC, 2003 for the antimony were not speci ed. 2007;39:189-92 27. Al-Qoatí of Toledo. [About medical matter]. In any case, kohl as an ocular 9. King James Bible. Kings 9, 30: Isaiah 54, 11; XII century CE. Quotations 144, 145 & 147. cosmetic is found abundantly in Chronicles 29, 2; Jeremiah 4, 30; Job 42, (Quoted by Gener Galbis29) many countries, including the U.S.A., 14. Ezekiel 23, 40. Quoted by Hirschberg1 28. Al-Gafiqi of Cordoba. Al-Mursid fi-Kuhl European Union, Russia, and others. 10. Babylonian Talmud. Shabbath 108b. V-VI [Oculistic guide]. XII century CE. (Quoted Most of the nonregulated kohl century ACE. Cited by Hirschberg,1 Gorin,11 by Gener Galbis29) cosmetics come from Pakistan, India, Geller,12 and Epstein13 29. Gener Galbis C. [The science of vision in and Indonesia. There it is called 11. Gorin G. History of ophthalmology. Wil- Andalusian Spain, X-XIII centuries]. Madrid, surma, and it is sold freely in small mington DE, Publish or Perish, Inc, 1982 Allergan, 1991. Spanish flasks that contain a high proportion 12. Geller MJ. An Akkadian vademecum in the 30. Prospero Alpinus. [About the medicine of Babylonian Talmud. Rotterdam, Kottek & Egyptians]. Venecia, 1591 of powder of galena (native lead fi Horstmanshof, 2000. pp 13-32 31. De Caluwé JP. [Saturnine intoxication from sul de). It is then introduced in other 13. Epstein I. The Babylonian Talmud, trans- the longterm use of kohl; an underestimated countries by tourists or by immigrants. lated into English with notes, glossary and cause in French-speaking countries]. JFr indices. London, Soncino Press, 1935 Ophtalmol 2009;32:459-63. and 2010;33:75. AUTHOR’S NOTE 14. Patkar KB, Bole PV. Herbal cosmetics in French Ocular cosmetics have a longstand- ancient India with a treatise on planta cosme- 32. Kassir M, Tham-Kassir H. [Cosmetic- ing tradition in all cultures. This essay tica. Mumbai (India), Bharatiya Vidya B. M., aesthetics and ophthalmology]. J Fr Ophtal- 1997 mol 2001;24:537-45. French has described their use in ancient times. 15. Rampa TL. The third eye. London, Secker & 33. 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JUAN MURUBE, MD, PHD, EDITOR

Ocular Cosmetics in Modern Times

JUAN MURUBE, MD, PHD

ecause all vertebrate species, pilosebaceous glands (which contain less intense color of the eyelashes. B including humans, obtain the pilous follicles and glands of Zeis Exceptionally, white eyelashes are due information from looking and Moll) and are situated not in to poliosis, or melanin deficiency, in into each other’s eyes, the eyes are often a continuous line on the lid rims, but some cutaneous areas.3-11 the first object of attention of people dispersed in the anterior part of the upon meeting each other. In humans, four lid rims in a band of about 0.4 B. Cosmetic Substances and the physical characteristics of youth mm wide between the lacrimal puncta Techniques are strongly associated with the concep- and the lateral angle of the lid junction. In recent years, many cosmetics have tual standards of beauty. With age, the There are about 100-150 eyelashes in been developed to conceal aging and/or position of the lids changes, the exposed the upper lid and 50-75 in the lower. disease-related conditions of the surface of the eye decreases, the lid’s Their mature length is 8-12 mm in eyelashes and lid skin, simulating normal skin loses surface uniformity and the upper lid and 6-8 mm in the lower, young eyelashes, enhancing the color, develops wrinkles, and its hue darkens. a little longer in the center of the lids. length, and thickness of lashes with Eyelashes decrease in number, length, In Mongolian races, the lashes are mascara, and coloring the tarsal lid skin thickness, and darkness, and their a little shorter and sparser.1,2 with pastes and liners (Figures 1 and 2). form and position change. In youth, In young people, the normal Almost two centuries ago, eye makeup enhances natural beauty; has a lifetime of 4-6 months. made a paste to be applied to the later, it can serve to simulate the attrac- When the eyelash physiologically drops eyelashes with the newly invented vase- tive characteristics of youth. out, the pilous follicle of the piloseba- line petroleum jelly combined with coal. In 1834, the French perfumer and ceous gland produces a new eyelash Later, new cosmetic pastes and creams businessman Eugène Rimmel (1820- that emerges in about 1 month. When were developed for the eyelashes, but 1887) emigrated to London, where his an eyelash is artificially pulled out, it despite differences in composition and father founded a cosmetic center. It is takes about 50-60 days to grow back. color, any type of cosmetic to coat the still there today, and has many subsid- Eyelashes are not cylindrical in eyelashes and change their appearance iary branches in other countries devoted shape, because their distal or terminal was given the generic name of rimmel. to inventing, manufacturing, and ends are thinner than the follicular (A similar generalization had occurred marketing eye shadows, mascaras, root and their axes are curved. Lashes with eau de cologne, which was origi- eyeliners, , and other cosmetics. are concave turning upward in the upper nally a water perfumed with lemon. Although the etymological meaning lids and concave turning downward in The Italian Giovanni Farina took it to of cosmetic (kosmhsikó2 ¼ designed to the lower lids. They are more or less the German city of Köln (in French, beautify and adorn) would encompass parallel to each other, with many varia- Cologne) and then to France in 1709 cosmetic surgical procedures, that area tions due to the curvature of the lid with some additions and changes. is beyond the scope of this paper, which rims, to differences in the position of Even though the current “eaux de will focus on preparations designed to the pilosebaceous follicles, and to differ- Cologne” are very different from beautify skin, hair or complexion. ences in size related to the stage of the Farina’s original, the term “eau de growing cilia. With aging, lash length Cologne” persists and is applied to I. EYELASHES and thickness diminishes, and their very different liquid perfumes.) A. Natural Characteristics of Eyelashes position and direction is more irregular. Although many new variants of In humans, eyelashes are present at Eyelash color is a little darker than eyelash cosmetics from other manufac- birth. They emerge from the hair and eyebrow color and has less turers received the generic name of rim- tendency to gray with aging. The mel, the popular term rimmel gradually Dr. Murube is Professsor of Ophthalmology, Middle-European Celtic race tends to became limited to the product of the University of Alcalà, Madrid, Spain. have reddish hair, and the Nordic- Rimmel trademark. Other similar prod- European Germanic races tend to ucts to coat the eyelashes began many © 2013 Elsevier Inc. All rights reserved. have yellowish hair, with similarly decades ago to be termed mascara.

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are unique to each brand. More gaudy century. In many cases, their applica- colored pigments, such as red, green, tion is combined with lid shadow. and ultramarine blue, are used to attr- act attention rather than to enhance C. Pharmacological Treatments a natural appearance of beauty. Heating and expression of the pilo- Substances applied to the lids are sebaceous and meibomian glands are usually removed daily. Therefore, the an attempt to maintain fluid secretion pH of their cleaning and removal prod- of the Zeis and Moll glands, and to ucts must have an acidity similar to that counteract age-related meibomian of the basal tear (ie, 7.4) and lack ethyl gland dysfunction with lid thermo- Figure 1. Shadow of the skin of the lower alcohol and any other cutaneous and massage once or twice a day to facilitate part of the tarsal skin of the upper lid. It surfocular irritants. Guillon identified ciliary growth.17-19 The number and simulates longer eyelashes (Courtesy of Carlota possible minor inconveniences of eye size of the eyelashes may partially or Gómez. Sevilla). cosmetics: mascara can facilitate the totally recover normality after several breakup of the lipid layer of the tear months of treatment. Recently, more The term mascara comes from the film; can distribute its parti- complex instruments have appeared. Arabic Spanish máshara and cles on the tear film surface and increase For instance,”hot spectacles” maintain máscara,12 which has the dual meaning debris formation; eyeliners applied a temperature of about 40-42 C of a covering for concealing the face or directly to the lid rim may block the between the goggles and the lid rims, a part of the face, and of a preparation orifices of the meibomian glands, and and the LipiFlow Thermal Pulsation for dyeing (coating) eyelashes. So, rim- their removal requires contact with the System heats the meibomian and pilo- mel or mascara now refers to a cosmetic lid edge and further disturbance of the sebaceous glands and compresses the paste applied to the eyelashes to adhere tear film.13 lids between a scleral and to their surface and join several of them In youth, the eyelashes are natu- a spherical sector placed on the anterior together, simulating longer, thicker, rally curled. Later, eyelash curlers surface of the lid.20 Age-related meibo- stronger, more numerous, and darker (electric or non-electric14) can produce mian gland dysfunction and associated lashes. this effect temporarily. Curlers are also blepharitis may improve with treatment Components of mascara vary used in rare cases in which hair from and rejuvenate the eyelashes. according to the different formulas of the head has been surgically trans- Parasitosis of the eyelash roots by the many manufacturers. The most planted to replace missing eyelashes acarus Demodex folliculorum or Demo- commonly used ingredients are oils or eyebrows. The transplantation tech- dex brevis is very common, leading (mineral, linseed, castor, eucalyptus, nique is similar to that used for hair gradually to blepharitis, oligotrophy, lanolin, turpentine, sesame) and waxes transplants on the head. As the hairs and malalignment of the eyelashes. (paraffin, carnauba wax, bees wax), but transplanted to the lashes maintain Rarely, the blepharitis causes trichiasis many other products can also be found their original characteristics, they or madarosis. The most common early among the ingredients. Some mascaras must be curled and curved to simulate treatment against the infestation by include stimulants to enhance growth normal eyelashes, and they will also Demodices was the topical application of the eyelashes. Tar and coal deriva- need to be trimmed regularly. to the lid rims of yellow mercury oxide tives are strictly prohibited by the Knapp15 and Wheeler16 took ointment. Today it is tea tree oil 50% FDA because of their toxic effect. a band of the skin from the eyebrows drops or foam, azithromycin 1%, and Brown/black color is typically pro- and implanted it in the anterior edge the cyclosporin A 0.05%.21,22 duced in mascara by use of iron oxi- of the lid rim. The direction of these Pharmacological stimulators of des, although the specific compounds hairs is different than the eyelashes, eyelash growth and darkness are the and this type of transplantation did collyria of prostaglandin analogs. It not gain popularity. was discovered by chance that many False, or artificial, eyelashes are patients being treated with topical pros- attached with eyelash glue to the lid taglandin analogs for chronic glaucoma rims in about half a minute. When experienced increases in the number, natural eyelashes are short or sparse, length, and darkness of eyelashes,23-25 the false lashes are applied as single as well as changes in iris color.25 One clumps to complement the natural of these analogs, bimatoprost, has been ones. If natural lashes are completely approved to treat eyelash deficiency.26,27 absent, the false lashes are applied as In contrast, some antiglaucomatous a full-set, extending from the front of topical medications of the beta-blocker Figure 2. Shadow on the skin of the whole the to the outer type (eg, Timogel, Timoftol, Betagan, upper lid (Courtesy of Marina Camblor. corner of the lids. False eyelashes etc.) have occasionally been associated Madrid). have been popular since the mid-XX with alopecia.28

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Interferon,29,30 cyclosporine, and of the upper lid produced by blinking Sun exposure also causes darkening drugs that target epidermal growth gradually produce increased elongation of the skin over time. Historically, factor7,31 may also stimulate the and laxity of the skin, diminishing the people who worked as farmers or growth of eyelashes. fold of the superior orbito-palpebral ranchers in the country developed concavity, and creating one or more brown skin, especially on the face and II. LID SKIN horizontal creases in the band covering backs of hands, which were more A. Skin Smoothness the of the preocular convexity of exposed to sun. Such darkening was The skin of the lids has a thickness of the upper lid. seen as a manifestation of middle or 0.3 to 0.8 mm, much thinner than on the In most Negroids and Caucasians, lower social class, so people tried to rest of the face. Open lids of a young when the eye is open in primary posi- avoid sun exposure by covering their Caucasian expose about 10 mm of the tion of gaze, the upper part of the faces and hands with hats, veils, or vertical diameter of the cornea, but as furrow of the upper lid hangs down gloves. During the 1800’s, both fashion- the upper lid descends with age, less of and its vertex approaches 2 or 3 mm able and working class women kept the cornea is seen; exposure of corneal of the lid rim, making it very evident, their skin as pale as possible. This began diameter is about 8 mm in a 60-year- sometimes even forming two skin to change in the 1900’s, when bathing in old person and about 7 mm in an 80- folds. In races, this skin swimming pools and at beaches during year-old person. upper fold hangs to the eyelashes, and the hot season became a sign of In an awake person, the eyes and this hanging fold, known as Mongo- economic success, elegance, and high the lids are in continuous motion lian, or epicanthic, fold, hides the social standing. By the later 1900’s, in (with normal blinking about 10 bottom of the wrinkle and makes it developed countries, vacationing in times/minute), with the upper lid appear that there is not a fold in the the sun was common in all social moving much more than the lower preocular convexity of the upper lid. classes, and the medical problems one. During sleep (about 8 hours/ The skin of the lower lid has very produced by excess of sun on the skin day), the closed and relaxed lid covers small vertical and horizontal displace- were evident. Protecting the skin with the entire ocular surface. ments and changes of position, which sunscreens and use of dark cosmetics The frequent movement of the are different when contracted with and tanning to replace natural upper lid, coupled with the natural blinking vs when relaxed in sleep.32 Sulci sun-darkened skin became common progressive laxity of the cutaneous or wrinkles are not present in young practice. In some Asian countries, skin tissues with age, causes the skin of the people, but they can appear with aging, whitening continues to represent the lids to lose the relative smoothness of mainly in the lateral part of the lid. ideal of beauty. In western countries, youth more than in other parts of the In both upper and lower lids, orbital this is less frequent (Figure 3). body. Linear macroscopic wrinkles are and subcutaneous palpebral fat can also Eye shadow to color the lid skin produced by a progressive excess of skin. modify the form of the lid skin surface. existed in pharaonic Egypt with use In a young person, the skin of the When it is excessive, it produces fat of the vegetable dye henna. Its use upper lid, when the eye is open in bags, a protrusion or droopy convex was spread by the Arabic Moham- primary position of gaze, has a concave surface, which may need be masked medan cultures. It was also used in depression under the eyebrows with eye make-up or removed with medieval Europe, and it is still used between the superior orbital rim and cosmetic surgery. When oribital and in some countries, sometimes with the prominence produced by the subcutaneous fat is deficient, the lid the addition of paraphenylene diamine eyeball, termed the superior orbito- surface may be deep-set, producing and p-toluidine diamine, which are palpebral horizontal concavity. Under a dark circle under the eye. The dark- toxic in high concentrations.33 this concavity begins a convex promi- ness can be lessened with a concealing Eye shadows in natural hues are nence of the lid due to the protrusion cream. In more extreme cases, it can used to maintain or simulate a youthful produced by the eyeball, termed the be treated with subcutaneous introduc- bulbo-palpebral lid convexity. After tion of autologous fat from another part birth, the skin of the superior orbito- of the body or hyaluronic acid. palpebral concavity and of the bulbo- palpebral lid convexity is smooth B. Skin Color when the lid is closed, but when the Various factors produce changes in eye is open, a more or less horizontal skin color with age. The age-related furrow appears in the horizontal band loss of tension of the skin causes of the skin covering the area of union a minute and diffuse irregularity of between the preseptal and the pretarsal its surface, almost imperceptible to skin surface of the bulbar convexity of the naked eye. However, the irregu- the upper lid. Age-related degeneration larity alters the brightness and color of the tissues (laxity, dermochalasis, fat of the skin, because the reflexion of Figure 3. Albino beauty (Courtesy of Klaire de Lys. London). bags, etc.) and the continuous traction the light is not uniform.

62 THE OCULAR SURFACE / APRIL 2013, VOL. 11 NO. 2 / www.theocularsurface.com SOURCES IN TIME / Murube appearance; other colors are used to polymers (eg, celluloses, proteoglycans, pressure of the precorneal part of the present a more dramatic, attention- sodium alginate, gamma-poly-glutamic upper lid.32 Thus, the piercing does attracting look. Natural-colored shadows acid) that extend over the lid skin. not create pressure on or scrape the are applied between the eyelashes and the They are also contained in many types eyeball with the bulbar conjunctiva. eyebrows. As the distance between the of mascara and eyelid shadow, and func- Although juxtaocular piercings upper lid rim and the eyebrow is greater tion as surfactant stabilizers and outside the lids are mainly done in in women than in men, a pale eye shadow humectants.35 the eyebrows, more rarely they may makesthisareaappearlarger,having Eye putty is a type of be done in the skin of the upper region a feminizing effect.34 Frequently, the used in East Asia in persons with epi- of the zygoma or in the glabella and upper part of the upper lid is painted canthic fold. It is a water soluble adhe- upper part of the nose. a little darker to simulate a deeper supe- sive flap, to be put behind the wrinkle In ancient times, henna was the rior orbito-palpebral concavity, which fold of the upper lid, fastening it to the most commonly used material to tattoo would, naturally, have diminished light. pretarsal lid skin, elevating the fold the body, mainly the hands and face, Eye shadows in unnatural hues are slightly. This makes it appear smaller including the lids.43 Its cosmetic use often applied in excessive and exagger- and younger, and increases the disappeared in many countries, and ated fashion, with no attempt to simu- opening of the lid and the exhibition its use became limited to correction of late a natural look (Figure 4). of the eyelashes. It takes only about scars, irregular eyebrows, and anoma- Common ingredients of eye shadow a minute for the anterior and posterior lous pigmentations. The popularity of are , talc, sericite, magnesium, and surfaces to adhere to each other. The tattooing has now re-emerged among other colorants that are not normally effect lasts for a few hours, and the young people as a sign of individuality rejected.34 The most common pigments putty can be easily removed.36 and self-affirmation.44 Currently, the used for non-natural colors are black Application of radiofrequency to the most commonly used micropigment iron oxide for giving a tonality without lid skin is a noninvasive procedure to is iron oxide. The emo culture, devel- brillance, manganese oxide for giving improve dermal laxity and fine wrinkles. oped in the last two decades among a yellowish or maroon tone, chromium It causes shrinkage of olddermal collagen some teenagers, is expressed in their oxide for a greenish hue, and ultrama- and new collagenesis in the most superfi- lifestyle, clothing, , tattoos, rine blue for a bluish color. cial skin layers. Most commonly, the etc. Tatooing of the lids with polychro- Some cosmetics are designed to procedure uses heat generated by matic figures is not uncommon. preserve the normal physiology and monopolar radiofrequency.37-40 Colored contact lenses are some- anatomy of the lid skin. These contain Other wrinkles near the eyes, such times used to conceal corneal nubeculae filters (titanium dioxide, as crow’s feet on the outer lid corner or scars, or to improve the vision in zinc oxide), hydrading substances (hya- and glabellar rhytids in the space cases of aniridia and albinism. They luronic acid, sodium lactate, alantoin), between the eyebrows, may be formed are also used in normal eyes, simulating antioxidants (vitamin A, vitamin C, or increased by muscular contraction. various color tones of the iris (brown, vitamin E), astringents (camomile, They may disappear with subcuta- light blue, green, yellowish, etc.), hamamelis, calendula), collagen stimu- neous or intramuscular local injection creating different designs in one, two, lators (extract of Asiatic centella), unsat- of , whose inhibitor or three concentric rings of the iris, or urated fatty acids (arachidonic acid, effect lasts about 3 months.41,42 changing the size or shape of the pupil.45 omega-3), and nutrients (vitamins, urea derivatives, tocopherols, elastin). III. SUPPLEMENTARY ADORNMENT Other cosmetics, termed filmogens, Intentional wounds and adornments, IV. LEGISLATION GOVERNING cover with a very thin film the micro- eg, eyebrow and lid piercings, and subcu- COSMETICS wrinkles formed by excess of skin, but taneous application of vegetable dyes or Current cosmetic laws in the USA do not impede the lid movements. These minerals, were common in prehistoric date back to 1938. The European Union filmogen substances are synthetic cultures on five continents. They have now returned, with various changes, to the universal common culture. Piercing of the eyebrows is quite common. Piercing of the eyelids is less common but is increasing. Lid piercings are usually done in the lateral part of the upper or lower lid (Figure 5). This is because, during blinking, the lateral third of the lid and the lateral palpebral ligament Figure 5. Piercing in the lateral region of the Figure 4. Lace eye (Courtesy of Klaire de Lys. become tight and tense, and the eyeball upper lid (Courtesy of Rodri Body Piercing. London). Madrid). is pushed backward about 1 mm by the

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