THERE IS CURRENTLY no lack of innovation in eye care, and this is very apparent in the field of dry eye disease diagnosis and treatment. However, as with most chronic conditions, while technology and ideas are exciting, a “stepladder” approach to treatment is generally recommended. The exception is when disease severity is such that lower-level therapies are likely to be insufficient. This ensures that treatment is the least invasive or aggressive (and often the least expensive) as is necessary to control disease progression and patient symptoms.
The second Tear Film & Ocular Surface Society Dry Eye Workshop report (TFOS DEWS II) outlines step one therapies that address the patient’s environment and diet and contributory systemic and topical medications, and include eyelid hygiene and warm compresses (Jones et al, 2017). Additionally, patients should be given a recommendation for a good quality topical lubricant/artificial tear. If they aren’t, they are left to choose one based on cost, name brand, or slogan recognition (“get the red out”), or a family member or friend’s recommendation.
The danger of patient-directed choices in artificial tears was particularly apparent in 2023 when numerous over-the-counter artificial tears were recalled due to cases of bacterial infection and findings of bacterial and fungal contamination (U.S. Food and Drug Administration, 2023). Unfortunately, even the practitioner’s artificial tear recommendation is often based on low-level evidence, such as personal or professional experience or (with even less scientific basis) because of what samples are most readily available to have in-office or offer the best profitability when sold in-store.
The primary role of artificial tears is relatively straightforward: they should lubricate the ocular surface and help to stabilize the tear film using some form of demulcent (Kathuria et al, 2021). Beyond this, other ingredients may be added to improve osmolarity (osmoprotectants), bind and retain water (humectants), or mimic the mucus or oil components of natural tears (Weng et al, 2023).
Multiple systematic reviews have been conducted to find the best artificial tear ingredients more definitively, but only a few broad takeaways have been established (Semp et al, 2023; Pucker et al, 2016):
1. Non-preserved tears are better than preserved formulations.
2. Avoidance of vasoconstrictors is recommended.
3. Increasing drop viscosity decreases the symptoms (and the signs, particularly with more advanced disease) but can negatively affect vision.
4. Drops with multiple active ingredients are more effective than single-ingredient options.
5. Dosing q.i.d. (four times/day) is generally recommended, though patient compliance with this regimen can be poor.
6. Drops containing liposomes may particularly benefit patients with evaporative dry eye disease.
There is little consistency in the results of studies comparing one drop or ingredient to another, and no clear winners when data is combined systematically. Still, while many patients can benefit from more advanced treatments, taking the time to discuss simple things like artificial tear use remains important to ensure that patients are employing this most basic type of dry eye care before moving to more aggressive options.
More investigation is needed to determine which artificial tear ingredients are best, though the answers will likely remain out of reach due to the incredibly large variability in the etiology and expression of dry eye disease itself. In the meantime, a practitioner’s recommended artificial tear is still likely to be better than one arbitrarily chosen by the patient. CLS
REFERENCES
1. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017 Jul;15:575-628.
2. U.S. Food and Drug Administration (FDA). FDA warns consumers not to purchase or use certain methylsulfonylmethane (MSM) eye drops due to contamination. 2023 Aug 22 [updated 2023 Aug 30]. Available at fda.gov/drugs/drug-safety-and-availability/fda-warns-consumers-not-purchase-or-use-certain-methylsulfonylmethane-msm-eye-drops-due. Accessed Oct. 26, 2023.
3. FDA. Global Pharma Healthcare Issues Voluntary Nationwide Recall of Artificial Tears Lubricant Eye drops Due to Possible Contanimation. 2023 Feb 24. Available at fda.gov/safety/recalls-market-withdrawals-safety-alerts/global-pharma-healthcare-issues-voluntary-nationwide-recall-delsam-pharma-artificial-eye-ointment#:~:text=Artificial%20Eye%20Ointment-,Company%20Announcement,due%20to%20possible%20microbial%20contamination. Accessed Oct. 26, 2023.
4. Kathuria A, Shamloo K, Jhanji V, Sharma A. Categorization of Marketed Artificial Tear Formulations Based on Their Ingredients: A Rational Approach for Their Use. J Clin Med. 2021 Mar 21;10:1289.
5. Weng J, Fink MK, Sharma A. A Critical Appraisal of the Physicochemical Properties and Biological Effects of Artificial Tear Ingredients and Formulations. Int J Mol Sci. 2023 Feb 1;24:2758.
6. Semp DA, Beeson D, Sheppard AL, Dutta D, Wolffsohn JS. Artificial Tears: A Systematic Review. Clin Optom (Auckl). 2023 Jan 10;15:9-27.
7. Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev. 2016 Feb 23;2:CD009729.