get the red out

How do "redness relief" eye drops work?

Short answer: "Redness relief" drops contain an ingredient that causes the superficial blood vessels of the eye to constrict, or narrow. 

Long answer: Brace yourself- it's about to get real nerdy up in here. Our blood vessel walls are made up of smooth muscle tissue. There are receptors in that smooth muscle tissue called alpha-adrenergic receptors. These receptors are activated by alpha-adrenergic agonists, which are agents that essentially stimulate the sympathetic (ie: fight or flight) response in the blood vessels. So when an alpha-adrenergic agonist binds to these receptors, it causes the muscle to contract, which constricts the blood vessels. 

Vascular smooth muscle has two types of alpha-adrenergic receptors: alpha 1 and alpha 2. The active ingredients in many of the redness relief drops on the market work by affecting only alpha 1 receptors, or both alpha 1 and alpha 2 receptors. File that away in your mind; we'll return to that shortly. Some common examples of drugs that behave this way: phenylephrine and tetrahydrozoline (alpha 1 only), and naphazoline and oxymetazoline (alpha 1 and alpha 2) (1). These are the ingredients commonly found in over-the-counter "redness relief" eye drops.

What is the active "redness-relieving" ingredient in some common eyedrops?

• Naphcon-A (Alcon): Naphazoline hydrochloride 0.025%
• Visine
• Visine Original Redness Relief: Tetrahydrozoline hydrochloride 0.05%
• Visine Advanced Redness and Irritation Relief: Tetrahydrozoline hydrochloride 0.05%
• Visine Maximum Strength Redness Relief: Tetrahydrozoline hydrochloride 0.05%
• Visine Totality: Tetrahydrozoline hydrochloride 0.05%
• Visine AC Ultra Itchy Eye Relief: Tetrahydrozoline hydrochloride 0.05%
• Visine A Multi-Action Eye Allergy Relief: Naphazoline hydrochloride 0.025%
• Rohto
• Rohto Digi Eye: Tetrahydrozoline hydrochloride 0.05%
• Rohto Ice: Tetrahydrozoline hydrochloride 0.05%
• Rohto Cool: Naphazoline hydrochloride 0.012% 
• Rohto Cool Max: Naphazoline hydrochloride 0.03%
• Clear Eyes
• Clear Eyes Redness Relief: Naphazoline hydrochloride 0.012%
• Clear Eyes Maximum Itchy Eye Relief: Naphazoline hydrochloride 0.012% 
• Clear Eyes Cooling Comfort Itchy Eye: Naphazoline hydrochloride 0.012%
• Clear Eyes Complete 7 Symptom Relief: Naphazoline hydrochloride 0.025%
• Clear Eyes Maximum Redness Relief: Naphazoline hydrochloride 0.03% 
• Clear Eyes Cooling Comfort Redness Relief: Naphazoline hydrochloride 0.03%
• Clear Eyes Triple Action: Tetrahydrozoline hydrochloride 0.05%
• Clear Eyes Traveler's Eye Relief: Tetrahydrozoline hydrochloride 0.05% 
• Clear Eyes Pure Relief Multi-Symptom: Phenylephrine hydrochloride 0.10%
• Bausch and Lomb
• Opcon-A: Naphazoline hydrochloride 0.02675%
• B&L Advanced Eye Relief Redness Reliever: Naphazoline hydrochloride 0.012%
• B&L Advanced Eye Relief Maximum Redness Reliever: Naphazoline hydrochloride 0.03%
• Lumify Redness Reliever: Brimonidine tartrate 0.025%

I personally do not recommend the majority of these redness relief drops. Why not?

Drops that affect alpha 1 receptors can lead to rebound hyperemia (translation: eyes become more red when you stop using the drop), and tachyphylaxis (translation: loss of effectiveness over time). 

Arteries carry oxygenated blood away from the heart to the body's tissues. Since alpha 1 receptors are predominantly in arteries, the drugs that act on these receptors cause constriction of the arteries, which decreases blood flow and thus oxygen flow to the tissue. Over time, the body adjusts to this lack of oxygen by down-regulating, or producing less of, the alpha 1 receptors. So this lessens the body's response to the drop (tachyphylaxis). With loss of effectiveness comes more frequent use, and more frequent use can possibly lead to toxicity from the preservatives in the drop (2). Overusing these drops can even cause your pupils to dilate!

When the drop is discontinued after a long period of use, the body's attempt to deliver more oxygen to the oxygen-deprived eye tissue is to dilate the blood vessels, which makes the eyes appear redder (rebound hyperemia). This can then cause a person to return to using the eye drop, and the vicious cycle goes on. 

What is Lumify?

Lumify is an over-the-counter eye drop that has been FDA approved for the relief of ocular redness due to minor eye irritations. It is approved for age 5 and older, begins working within 1 minute of instillation, and provides up to 8 hours of redness relief. 

The active ingredient in Lumify is brimonidine tartrate (0.025%). Brimonidine tartrate (in higher concentrations) has long been used as a medication to lower eye pressure. It is also used in ocular surgery to control bleeding. In gel form, it is used to treat facial redness due to rosacae in adults. 

How is Lumify different than all of the other redness relief drops out there?

Brimonidine tartrate is a selective alpha-2 adrenergic receptor agonist. Recall that all of the other drops mentioned above work on either alpha 1 only or both alpha 1 and alpha 2. Because of Lumify's selectivity, its effect is primarily on the veins and not the arteries. Thus, Lumify does not have as significant of an effect on oxygen flow, which reduces the oxygen-deprivation that triggers those negative side effects. In Phase 3 clinical trials, Lumify showed no evidence of tachyphylaxis and minimal rebound hyperemia (3). 

But WHY are your eyes red?

There are numerous conditions/factors that can make eyes red: dryness, allergies, contact lens overwear, uveitis, infection, foreign body, exposure to smoke or other irritants, fatigue, etc. Don't just buy a drop to mask the symptom; see an optometrist to determine and address the source.



--> CliffsNotes: Redness relief drops can have unwanted side effects, so I don't recommend frequent use of drops like Visine, Clear Eyes, Rohto, etc. Lumify's unique mechanism of action avoids these unwanted side effects. If your eyes are red, it's best to start by seeing your optometrist to figure out why they're red.

*Dr. H has no financial interests in any of the products mentioned*

eye makeup safety tips

As an optometrist, I get up close and personal with a lot of eyes. I see a fair amount of complications related to not-so-great eye makeup habits, so I wanted to share my top 10 eye makeup tips (from an eye health standpoint). 

1. Don't apply makeup inside the lash line.

This tops my list of eye makeup no-nos. "Waterlining" is the practice of applying eyeliner directly on the waterline. The waterline is the thin area between the eyelash line and the eye. Within that area are the openings of your meibomian glands. Meibomian glands secrete oil onto the front surface of the eye to help keep your tear film stable and your eyes moist and comfortable. Applying makeup inside the lash line can block these important glands, which can cause meibomian gland dysfunction (MGD). If the oil is not being secreted onto your tear film properly, your tears evaporate more quickly and your eyes are more dry. Dryness can manifest as a burning sensation, a sandy/gritty feeling, redness, tearing, and discomfort. Meibomian glands can also get infected (this infection is called a hordeolum, commonly referred to as a stye), so keep makeup away from the waterline!

Image via All About Vision

Makeup applied inside the lashline is also more likely to migrate into the eye and contaminate the tear film when compared to application outside the lash line (1). This presence in the tear film can cause irritation (especially for contact lens wearers) and tear film instability, which is a factor in dry eye disease.

Avoid applying eyeliner on the waterline, as demonstrated on the left
Image via Beauty Insiders

Beyond affecting your tear film stability and potentially causing infection, applying makeup inside the lash line can cause the makeup to build up in the eye over time and cause irritation. Below is an example of this. One of my patients came in reporting red and irritated eyes for several weeks. After examining her eyes, it appeared that she was applying a nude eyeliner to the water line, and that same nude eyeliner was found deposited in her lower eyelid tissue (the palpebral conjunctiva). When we discussed the findings, she realized that her symptoms began shortly after she adopted a new makeup technique she found on a YouTube tutorial. 

The arrow is pointing to some of the nude eyeliner particles that have become
embedded in the conjunctival tissue of the lower lid

Something else you shouldn't put on your waterline? Bling. That's right. Apparently, it needs to be said.

Don't do this. Just don't.
Image via Allure

2. Replace mascara and eyeliner every 3 months.

Liquid and cream makeup can be a breeding ground for bacteria. Get in the habit of cleaning out your makeup bag every quarter and replacing your mascara, eyeliner, etc. If you develop an eye infection, throw out your old makeup and start fresh. 

3. Don't sleep in your makeup.

You know this. But it happens. This is a report on a 50 year old woman who admitted to heavy mascara use with inadequate removal for 25+ years. The below photo shows mascara particles embedded in the tissue that lines the upper eyelid. Thoroughly clean your lids and lashes every night! After removing makeup, gently scrub along the lid margin with a premoistened wipe or a q-tip dabbed with a lash/lid cleanser. I recommend using a product that contains diluted tea tree oil, but avoid getting it IN the eye. Tea tree oil is effective against eradicating a mite that lives amongst your lashes (more on that in a previous post). Some of the products I frequently recommend to patients: Blephadex, Cliradex, We Love Eyes. *I have no financial interests in any of these companies- just sharing my recommendations!*

Mascara particles embedded in the conjunctival tissue
Image via Ophthalmology

4. Don't apply mascara in a moving vehicle, or use a sharp object to separate your lashes.

This may seem obvious, but it needs to be said. Mascara wands are a common cause of corneal scratches or abrasions. Keep sharp things away from your eyes!

Corneal abrasion from a mascara wand
Image via Clinical Optometry

5. Avoid using makeup that flakes. 

Glittery eyeliner is an example- the glitter particles can enter your eye and swim around in your tearfilm, irritating the eyes and adhering to contact lenses. 

Fiber mascara is another no-no in my book. The fiber particles often flake off and enter the eye, causing irritation and inflammation. 

This image shows glittery makeup particles within the tear film

6. Stop using a product if your skin/eyes become irritated, red, and swollen. 

It could be an allergic reaction to a new product. It's a good idea to patch test new makeup on your hand or arm before using it on/around your eyes. 

If you experience symptoms of redness, irritation, pain, itching, and/or dryness, discontinue makeup use and see your optometrist. This also applies to eyelash enhancers; there are many out there that cause inflammation and irritation of the eyelid margins. 

7. If you wear contact lenses, opt for daily disposable contacts. 

If there are any makeup particles adhering to your contact lenses, daily disposable contacts allow you to just throw them away at the end of the day. So you're not worrying about makeup deposits accumulating on your lenses day after day. 

8. Keep makeup brushes clean.

Bacteria and dust collect over time, so keep your makeup applicators clean.

9. Avoid eyelash extensions.

Blasphemy, I know. But just hear me out, and do with it what you will. 

Many of the complications I see relating to eyelash extensions stem from neglecting to clean the lash line well. With how expensive eyelash extensions are, I can understand being super cautious about bringing anything near them! Bacteria and dirt can collect and get trapped around the base of the lashes, causing irritation and infection. If you have eyelash extensions, avoid wearing mascara and oil-based makeup on or around the extensions. Use an oil-free cleanser on your lash line daily, gently cleaning the lash line using a bristle brush or spoolie (cotton can snag, so avoid that). Oil-based makeup removers weaken the adhesive and can cause the extensions to fall out prematurely, so use oil-free cleansers (thus, the tea tree oil cleansers I recommended earlier would not be a good option for those with extensions). 

The glue used to adhere eyelash extensions may contain formaldehyde, which can cause an allergic reaction. Ask your aesthetician what ingredients are in the glue he/she uses.

Dislodged or loose extensions, or flakes of glue, can rub against the eyelid and/or the cornea, which causes extreme irritation. If that happens, see an optometrist to remove the offending lash/particle. 

Eyelash extensions can also damage your natural eyelashes and even damage the hair follicle, which can slow down or halt hair growth. 

The best way to avoid these complications is obviously to avoid eyelash extensions. However, if you choose to go that route, here are some tips:

• Make sure you look into the certifications and experience of your aesthetician
• Choose a reputable salon that is safe and hygienic
• Ask about adhesive ingredients beforehand
• Avoid wearing mascara and oil-based makeup with eyelash extensions
• Clean lashes daily with an oil-free cleanser
• See an eye doctor if you develop redness, irritation, etc. 

10. Don't borrow or share makeup.

Sharing makeup introduces more bacteria and increases the likelihood of infection. Sampling makeup at a beauty counter is not a great idea, especially if multiple people sample the same bottle of product. 

CliffsNotes: 1) Don't apply makeup to the waterline, 2) Replace mascara and eyeliner every 3 months, 3) Don't sleep in your makeup, 4) Don't apply mascara in a moving vehicle or use sharp objects to separate lashes, 5) Avoid using makeup that flakes, 6) Stop using a product if your skin/eyes become irritated, red, and swollen, 7) If you wear contact lenses, opt for daily disposable contacts, 8) Keep makeup brushes clean, 9) Avoid eyelash extensions (if you must use them, be safe and keep them clean!), and 10) Don't borrow or share makeup.

Additional Recommended Resources:

• American Optometric Association: Cosmetics and the Eye

Essential Eye Nutrients

Food and lifestyle choices can influence your eye health and may help to reduce the risk of some age-related eye diseases.  Check out this quick summary of the nutrients essential for good eye health.
*Disclaimer: I am not a nutritionist or a dietician.

• Zinc (red meat, poultry, oysters, beans, fortified cereal)
• The Food and Nutrition Board recommends: 11 mg/day for males, 8 mg/day for females
• Zinc is an essential mineral that is involved in cell metabolism.  It is highly concentrated in the retina and choroid of the eye.
• Vitamin E (nuts, seeds, vegetable oils)
• The Food and Nutrition Board recommends: 15 mg or 22.4 IU/day for both males and females
• Vitamin E is a powerful antioxidant that is involved in immune function.
• Vitamin C (citrus, strawberries, broccoli, red and green pepper, kiwi)
• The Food and Nutrition Board recommends: 90 mg/day for males, 75 mg/day for females
• Vitamin C is an antioxidant that helps absorb UV radiation. It is found in high concentrations in the lens, aqueous humor, and vitreous humor of the eye.  On a long term basis, increased intake of vitamin C (alone or in combination with other antioxidants) has been shown in some studies to reduce the risk of developing nuclear sclerotic cataracts (1, 2).

The National Eye Institute's Age-Related Eye Disease Study (AREDS) found that daily intake of 80 mg zinc, 2 mg copper, 500 mg vitamin C, 15 mg beta carotene, and 400 IU vitamin E could reduce the risk of progression to advanced Age-related Macular Degeneration (AMD) by about 25% and visual acuity loss by 19% in individuals at high risk for the disease (3).  Since that study, researchers have found that substituting beta carotene with 10 mg lutein and 2 mg zeaxanthin is safer and more effective (4).

• Vitamin A (beef liver, carrot, pumpkin, sweet potato)
• The Food and Nutrition Board recommends: 900 micrograms or 3000 IU/day for males, 700 micrograms or 2300 IU/day for females
• Vitamin A is essential in the proper functioning of the retina, as well as the conjunctival membrane and cornea.  Most Americans get sufficient vitamin A from their diet, but vitamin A deficiency (VAD) is actually the leading cause of preventable blindness in children world-wide (5).
• Lutein (kale, spinach, collards, egg yolks) & Zeaxanthin (gogi berries, orange peppers, corn)
• The American Optometric Association recommends: 10mg/day of lutein and 2mg/day of zeaxanthin
• Lutein and zeaxanthin are carotenoids that are abundant in the macula of the eye as well as the lens. They are antioxidants that help lower your risk for Age-related Macular Degeneration (AMD) and cataracts.

From Review of Optometry

A follow-up to AREDS- AREDS 2- found that people with the lowest dietary levels of lutein and zeaxanthin who added supplements of the two had a 26% reduced risk of developing advanced AMD.  Those with the lowest dietary intake of lutein and zeaxanthin also saw a 32% risk reduction in progression to cataract surgery with the introduction of these nutrients (6).  Most Americans only get 1-2 mg of lutein and zeaxanthin combined on a daily basis through their diet, so many of us fall into this category.

Fun Facts: Vitamins A, D, E, and K, as well as lutein and zeaxanthin, are fat-soluble.  A small amount of dietary fat (ie: olive oil, avocado, nuts, seeds) can help maximize the body's absorption of these nutrients.  Cooking (steaming, sautéing, or puréeing) leafy greens actually allows more access to the important nutrients by breaking down plant cell walls.

• Omega-3 Fatty Acids (wild salmon, mackerel, tuna, sardines)
• The American Heart Association recommends eating at least two servings of fish (especially oily fish)/week
• The 3 types of omega-3 fatty acids the body uses are ALA, DHA, and EPA.  DHA and EPA have structural and protective functions in the retina, and they also have anti-inflammatory properties.  Beyond the cardiovascular health benefits, diets rich in DHA and EPA have been linked to a significant improvement in dry eye symptoms (8, 9). 

Eye vitamins and other supplements can help you meet your recommended daily intake of these nutrients. Be sure to discuss this with your optometrist or ophthalmologist.  I also recommend communicating with your primary care doctor before beginning any supplementation regimen- it's important to give your PCP the full picture of what you do to manage your health.

If you want to find an optometrist that specializes in ocular nutrition, look here.

CliffsNotes: What you eat can influence your eye health and may help to reduce the risk of age-related eye diseases.  

Additional Recommended Resources:

• AOA: Diet and Nutrition
• All About Vision: Nutrition
• Get EyeSmart: Diet and Nutrition
• Eyefoods: A Food Plan For Healthy Eyes
• Visionary Kitchen: A Cookbook For Eye Health