August 19, 2019
5 min read

Artificial tears are important: why and how to use them

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Once upon a time in Ozthalmology, the yellow brick road to treatment was lined by nothing but bottles of artificial tears and — yikes — Visine. Everybody and nobody was an eye doctor who treated dry eye back then because everything worked and did not work just about the same for dry eye. I used to send DED patients to the pharmacy with advice that was equally colorful and vague. “Go buy some artificial tears. Get the most expensive ones or the cheapest. Buy the biggest box or the smallest one. I really like purple.

“Buy any artificial tear that comes in a purple box.”

Seriously, it was that silly.

Now? Is it still the same game in the age of Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) and Xiidra (lifitegrast ophthalmic solution 5%, Novartis), a time when half of the presentations at the Ophthalmology Innovation Summit are about new DED products? Every single executive and a supermajority of doctor-experts in the DED space incessantly beat a “tears don’t treat DED” drum, the implication being that the whole artificial tear market could just dry up, disappear, and no one would shed a tear (see what I did there?). But is that really the case? Is there no value in the use of artificial tears now that we have a plethora of medicines, and even a device or two, that will treat the causes of DED? Given the headline of this column, it should be obvious that I find artificial tears to be a useful part of our DED armamentarium.

The simple fact that patients have access to over-the-counter eye drops is a boon to everyone who is interested in the complete care of their eye patients. There are no fewer than five verified patient surveys that will tell us whether or not an individual has dry eye, and from some, how bad that dry eye might be. Some of them are useful (OSDI, SPEED), and a couple of them have the blessing of the FDA for use in clinical trials (VAS). Not all of them are my cup of tea, as I noted in an older blog post on SANDE; in retrospect, SANDE may be more useful than I originally thought, although it is still low on my personal list. However, if all you are trying to do is decide whether or not a patient should be worked up for DED, you could do much worse than simply asking them one simple question:

Do you take eye drops?


Really. It is probably just that simple. You do not even have to ask them why because the overwhelming majority of them will go on to be diagnosed with some form of DED regardless of what they think they are actually treating. How often do you make a firm, confident diagnosis of allergic conjunctivitis, not a “get out of my chair so I can see a preop” one when a patient is taking Alaway (Bausch + Lomb)? It does not happen all that much. When your patient comes in taking OTC drops of any kind, it is most likely that they have DED, which makes artificial tears a diagnostic medication.

On the shelves of local pharmacies (and the pages of Amazon Prime), there are four different types of artificial tears: referral, general purpose, hypotonic and oil-based. Referral tears are there to fail so miserably that they will prompt your patient to seek your help (see above paragraph). Think pretty much any artificial tear that bears only the name of a “brand” manufacturer (eg, “Bausch + Lomb Tears” with no other qualifier) or the house name (“CVS Tears”). As you may know, these have recently been in the news due to contamination issues at the factory level. They are certainly not the benign OTC category they were a month ago.

Perhaps the most important category of artificial tears is the general purpose (GP) tear. I like to think of them as the utility infielder of tears, able to play a number of positions/do a number of things, just not as well as the single-position superstar. These are the drops you start for a patient when they have come into the office for a vision plan exam that does not include coverage for testing or that patient who has soft symptoms who you just know is going to be back in a year or two with 2+ superficial punctate keratitis (SPK) and an OSDI of 50. You are introducing the DED diagnosis to them with the GP tear. They are also a great substitute for the referral tear a patient was taking. Traditional options such as Refresh (Allergan), Optive (Allergan) and Systane Ultra (Alcon) are mainstays. I think newer offerings such as Refresh Repair and Systane Complete fit here, too.

Those of you who are a bit long in the tooth will remember the first real breakthrough tear, HypoTears. While not a terrific product overall, Hypo­Tears did address what we now know as one of the root causes of all things dry eye: hyperosmolarity. If you use tear osmolarity in your DED workup, you can make an objective decision on which tear to prescribe as part of your therapeutic regimen: high tear osmolarity (TO) = hypotonic tear. Blink Tears (Johnson & Johnson Vision) (but not Blink for Contacts) and TheraTears (Akorn) are modern examples of this category, and both are excellent choices. If you do not have access to TO, the presence of SPK is highly suggestive of elevated TO. As an aside, it is astonishing how many ophthalmology residency programs do not have TO in the clinic; this is borderline shameful.


Last, but certainly not least, we have a relatively new category of artificial tears, the group that we call oil-based tears. So much of the DED that we see in our offices is primarily evaporative and so often associated with a lipid “layer” that is underperforming. At the slit lamp, a rapid tear breakup time is your exam cue to consider oil-based artificial tears in your eventual recipe for success. If you do have the ability to check TO, the combination of a low TO and a quick tear breakup time is a clear signal to use a tear such as Systane Balance, Soothe XP (Bausch + Lomb), Retaine MGD (OCuSOFT) or the newcomer (and new champ at SkyVision) Refresh Optive Mega-3. While you must still endeavor to uncover and treat the underlying pathology behind the evaporative DED, using oil-based artificial tears does bring some relief to many patients.

Prescribe artificial tears as if they were a prescription. Give your patient a couple of specific options in the general purpose, hypotonic or oil-based categories, and write out a sig. For example, “Refresh Optive Mega-3 one drop in each eye 4×/day.” (That name, though. Note to Allergan: You came up with Restasis. This is the best you can do?) Your patient will go buy what you tell them to buy, especially if you give them that exact sample (a reality that is maddeningly hard to convey to eye care pharma). Encourage them not to economize by educating them about the importance of using a true, well-designed and effective product.

Some of them even come in a purple box.

Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.