Download not All Artificial Tears Are the Same

cover story
Dry Eye Disease:
Not All Artificial
Tears Are the Same
Physicians need to prescribe tears for their patients.
By Kirk Smick, OD
A
n estimated 40% of Americans suffer from
chronic or occasional dry eye disease (DED)1;
however, one treatment does not fit all.
Although artificial tears are a mainstay in the
management of this condition, there are a variety of
formulations on the shelves, patients are often overwhelmed by the choices, and may not understand the
differences between the products.
When choosing a tear for a particular patient, it is
important to consider the underlying cause of the DED
and how often the patient will be instilling drops. Based
on disease severity and dosing, consider whether a
patient would be better off using a preserved or nonpreserved formulation, whether he or she is suffering from
an aqueous deficiency, mixed disease, or an evaporative form of DED, and whether the condition is severe,
moderate, or mild. All of these circumstances inform my
decision-making process.
Some formulations contain “vanishing” preservatives.
In these preparations, the preservatives turn into water
or a nontoxic chemical when they are exposed to air or
mix with the tear film. It is important to note, however,
that preservative-free products can be more expensive
than drops with a preservative.
Another important consideration when choosing
an artificial tear for a patient is the agent’s viscosity.
Practitioners may prefer a watery drop for patients with
mild DED and a thicker drop like a gel or an ointment
that stays on the cornea longer for those with more
severe disease. This concept of residence time is important to consider. More viscous drops can cause blurring
of vision, so they may not be ideal during the day, especially when driving or using heavy machinery.
Some of the preparations include a lipid and an aqueous component in an attempt to mimic the biphasic
nature of natural tears.
AVAILABLE FORMULATIONS
Most formulations contain a preservative, allowing
one bottle of drops to be used over time. Formulations
without a preservative are typically single-use vials.
In recent years, there has been some debate about
whether the preservatives used in artificial tears are
safe. Although there are advantages to preparations
that are preserved, the toxic effects of benzalkonium
chloride are well known. Fortunately for patients with
severe DED or who are hypersensitive to preservatives,
there are some useful preservative-free drops on the
market.
PRESCRIBING DROPS
In my practice, I prescribe artificial tears, even though
they are available over the counter. My everyday preference is Blink Tears (Abbott Medical Optics Inc.),
although I use several others depending on the condition. I provide written communication to the patient so
that there is no question about which artificial tear he or
she should be using. This communication can be done
using a traditional prescription pad or with electronic
prescribing. Either way, patients receive specific instructions regarding which formulation to use.
Some of my patients use a less viscous drop during
64 Advanced ocular care may/june 2013
cover story
the day and then a gel or an ointment at night. For
patients with severe disease, it may be ideal to prescribe
a gel or an ointment to be used around the clock, but
if they are driving or working during the day, that may
not be possible.
The bottom line is that it is our responsibility as
optometrists to look at the research and recommend
or prescribe the most appropriate drop or combination
treatment for each patient. For a patient with mild DED,
I may prescribe only artificial tears. If he or she has more
advanced disease, then I may prescribe a steroid in addition to the tears. For patients who have red eyes, steroids
will help make them whiter.
If a patient has a more advanced case of DED, I will
start him or her on loteprednol 0.5% (Lotemax, Bausch
+ Lomb) drops for a couple of weeks. This helps the
patient feel better, but he or she cannot take steroids
long term because of the risk of increased intraocular
pressure. Then, I switch the patient to cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan, Inc.). These
are patients who, because of the nature of their discomfort, will probably end up using artificial tears every hour
or two. It is important for them to know that they can
use artificial tears between doses of Restasis to maintain
comfort.
I would expect that, in many cases after 3 to 6 months
of treatment, that the patient’s dependence on artificial
tears becomes less as his or her body starts reacting to
the Restasis.
CONCLUSION
It is never appropriate to let the patient choose his
or her own artificial tears through trial and error. We
optometrists should have an idea ahead of time based
on the patient’s complaints and our knowledge of the
preparations on the market which type of artificial tears
might be most appropriate for the patient, and we
should make a recommendation. Otherwise, patients
may assume that all of the preparations are interchangeable and will just choose the most inexpensive
one.
Eye care providers need to take a proactive approach
in educating patients about artificial tears and finding the
formulation that is best for each patient. n
Kirk Smick, OD, is in private practice at the
Clayton Eye Center in Morrow, Georgia. He has
been a consultant to Abbott Medical Optics Inc.
Dr. Smick may be reached at [email protected].
1. Multisponsor surveys, Inc. Gallup study of dry eye sufferers. Princeton, NJ, August 2005.