Dropping The Bomb: Making the right choice of OTC tears for your patients

5 12 2012

Variability of symptoms is the hallmark Dry Eye Disease (DED).  From the asymptomatic diabetic patient with corneal hypoaesthesia to the contact lens intolerant patient who has no ‘apparent’ corneal findings and  drops out of lens wear – basing therapies on symptoms may lead the eye physician in the wrong direction.  Clinical signs are key, but as important is the recommendation for the correct over-the-counter product to suit the needs of the patient.  Retail pharmacies have  several feet of choices that should be directed by a doctor to ensure symptomatic improvement and prevent further insult to the ocular surface.

Oil Emulsified

With the majority of our patients having some component of dry eye stemming from lid disease related evaporation, it makes sense to supplement the tear film with a stabilizing component like our naturally occurring lipid layer.  Systane Balance (Alcon) and soon to arrive in Canada Optive Advance (Allergan) are two good examples of oil emulsified drops which help to replicate the biphasic nature of the tear film.  This better allows the aqueous component to be evenly distributed over the ocular surface, and slows evaporation.  Note that mineral oil is part of the composition, which helps to neutralize fatty acids found in frothy tears – these fatty acids contribute to the burn and can also cause angular blepharitis.

Mineral Oil is an excellent adjunct to maintaining the lid surface.  Try applying to the lid margin with a cotton-tip applicator on patients with frothy tears.  It not only soothes the surface, but neutralizes the acidic insult to the meibomian gland orifice.

Preservative Free

The necessary evil of benzalkonium choride has been a thorn in the ocular surfaces side since inception.  Studies continue to show that exposure to BAK 0.1% causes a decrease in nerve fibre density and a reduced aqueous tear production.  In patients with noted hypersensitivity to BAK (most eyes), there are now a plethora of good options like Refresh (Allergan), Systane (Alcon) and TheraTears available in unit doses.  Albeit more expensive to the patient, the chronic dropper should be directed towards non-preserved topical options.

Hyperviscous Agents

Use of thicker eye drops can be a double-edged sword.  The blurry vision, and crusty debris laiden tearfilm from residual particles can often worsen symptoms; however with a new light uncovering exposure and impartial blinking  due to the micro-anatomy of the lids (Line of Marx and lid seal) in more and more patients a hyperviscous solution may be warranted.  Liposic Gel (Bausch and Lomb) and Refresh Liquigel (Allergan) sit closely by my dry eye clinic chair and are valuable tools in my kit.

Now this list is by no means exhaustive but by making clear and specific prescribed directives to our patients can set them up for success in a potentially dry world.  Understanding that the eyelids have a very large role to play in the dry eye world and maintaining them first is key in managing this patient base.  Throwing water blindly at the eye may not be the solution, but when needed there are some very useful OTC drops for each case.  Don’t let your patients choose the wrong one – make the choice for them because they aren’t all the same!

Dr. Richard Maharaj OD FAAO


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