Which Artificial Tears should you use?

Artificial Tears

Carboxyl Methylcellulose (CMC) Artificial Tears

Optive Carboxymethylcellulose Sodium 0.5%, Purite preserved.

contains compatible sloutes (Glycerin 0.9%, Erythritol , Levocarnitine) which protect
against cell damage by hyperosmolar tears (OSMOPROTECTION).
RECOMMENDED for Mild to Moderate dry eyes.

Refresh Tears 0.5% CMC

Purite as preservative. Refresh Plus Tears also has 0.5% CMC, but is preservative
free & comes in single use vials.

Refresh Liguigel 1% CMC

Purite as preservative. Refresh Celluvisc also has 1% CMC, but is preservative free
& comes in single use vials .

Thera Tears 0.25% CMC, HYPOTONIC

Preservative Free.

Polyethylene Glycol Artificial Tears

Systane Polyethylene Glycol 400 0.4% (lubricant), Propylene Glycol 0.3% (lubricant),
Hydroxypropyl Guar (GEL FORMING MATRIX)
Polyquaternium-1 as preservative.

Systane Ultra This is an improvement on original Systane. The delivery system ensures minimal
blurring of vision. In the bottle, Systane Ultra consists of a loosely crosslinked
meshwork created by interactions between borate and HP-Guar, which is kept loose
due to the presence of sorbitol. Upon instillation HP-Guar forms a stronger, tighter
viscoelastic gel that covers and lubricates damaged corneal cells.
RECOMMENDED for Mild to Moderate dry eyes.

Blink Tears Polyethylene Glycol 400 0.25% (lubricant), Sodium Chlorite (preservative)
has HYALURONIC ACID (HA), which promotes healing of the corneal epithelium.
RECOMMENDED for Moderate to SEVERE dry eyes.

Hydroxypropyl Methylellulose (HPMC) Artificial Tears

Bion Tears 0.3% HPMC, 0.1% Dextran 70. (bicarbonate & zinc help mucus & surface cells)
Preservative-Free.

Tears Naturale Forte 0.3% HPMC, 0.1% Dextran 70, 0.2% Glycerin
Polyquad 0.001% as preservative.

Tears Natural II 0.3% HPMC, 0.1% Dextran 70

Polyquad 0.001% as preservative.

Tears Natural Free 0.3% HPMC, 0.1% Dextran 70

Preservative-Free.

Genteal 0.3% HPMC

GenAqua (Sodium Perborate) as preservative. Genteal is also available as
Preservative Free single-use vials

Genteal Mild 0.2% HPMC

GenAqua (Sodium Perborate) as preservative.

Visine tears 0.2% HPMC, 0.2% Glycerin, 1% Polyethylene Glycol 400

Benzalkonium Chloride (0.01%) as preservative. Visine is also available as
Preservative Free single-use vials

Glycerine Artificial Tears & Others

Advanced Eye Relief Dry Eye 1% Glycerin

Environmental Benzalkonium Chloride (0.01%) as preservative.

Computer Eye Drops 1% Glycerin

Benzalkonium Chloride (0.01%) as preservative.

Moisture Eyes 1% Propylene Glycol, 0.3% Glycerin

Benzalkonium Chloride (0.01%) as preservative.

Similasan Dry Eye Relief Belladonna HPUS 6X alkaloids, Euphrasia, Mercurius sublimatus.
Sodium silver chloride complex 0.001% as preservative.

Soothe Lubricating Eye Drops Glycerin (0.6%) - Lubricant Propylene Glycol (0.6%) - Lubricant
boric acid, hydroxyalkylphosphonate, purified water, sodium alginate, sodium borate

Polyvinyl Alcohol (PVA) Artificial Tears

Murine Tears 0.5% Polyvinyl Alcohol , 0.6% Povidone. (has Bicarbonate)

Benzalkonium Chloride (0.01%) as preservative. Manufactured by Ross (Abbott Labs)

Hypotears 1% Polyvinyl Alcohol , 1% Polyethylene Glycol 400. HYPOTONIC

Benzalkonium Chloride (0.01%) as preservative. Hypotears is also available as
Preservative Free single-use vials

Akwa Tears 1.4% Polyvinyl Alcohol. HYPOTONIC

Benzalkonium Chloride (0.005%) as preservative.

Tears Again 1.4% Polyvinyl Alcohol.

Oil Containing Eye Drops - Prevent Evaporation of Tears

Refresh Endura Castor oil, polysorbate-80, Carbomer 1342 & Glycerin

Preservative Free.
RECOMMENDED for Blepharitis & Evaporative dry eyes.

SootheXP Emollient Eye Drops Light mineral oil 1.0%, Mineral oil 4.5% (Restoryl), polysorbate-80
Polyhexamethylene biguanide as preservative. RECOMMENDED for Blepharitis &
Evaporative dry eyes.

Contact Lens Rewetting Drops (can be used while wearing soft or hard/gas permeable contact lens)

Clerz Plus Tetronic 1304 helps lens retain moisture & shields from protein build up. RLM-100
removes lens deposits. Polyquad is the preservative.

Aquify Comfort Drops Sodium Hyaluronate 0.1%

Sodium Perborate is the preservative.

Complete Blink-N-Clean Hydroxypropyl methylcellulose is the lubricant, tyloxapol is the surfactant.

polyhexamethylene biguanide is the preservative.

Opti-Free Express Rewetting drops Sterile, buffered, isotonic, aqueous solution. No hydrogel lubricants.
Polyquad is the preservative.
 Normal tears are composed of water,
electrolytes, small molecules such as
carbohydrates and lipids, and a variety of
proteins, several of which have an enzymic
function. The principal proteins of tears include
lysozyme (an enzyme which attacks bacterial
cell walls), lactoferrin (a bacteriostatic protein),
secretory IgA antibodies, and lipid binding
proteins.
The use of artificial tears has obvious
limitations. Artificial tears cannot completely
substitute complex composition of natural tears.
The integrity of the three-layered lipid, aqueous,
and mucin structure, vital to the effective
functioning of the tear film is not reproduced. Artificial tears act by adding volume of the tear film, but
they can only do this while they remain in contact with the surface of the eye. A simple saline eyedrop
will remain in contact with the eye surface for only a few seconds. Therefore to be effective, a viscosity
enhancing component is required in the artificial tear formulation.

Hydrogels are the viscosity enhancing active ingredients of artificial tears. Hydrogels
make the artificial tears more viscous so they stay on the eye for longer time. The mucous adhesive
property of hydrogels also help in prolonging the time tears stay on the eye. Hydrogels are actually
polymers that are endowed with the property of swelling up in water and retaining the moisture. The
following hydrogels have been used in artificial tears: Hydroxypropyl Methylcellulose (HPMC), Carboxy
Methylcellulose (CMC), Polyvinyl Alcohol (PVA), Carbopol, polyvinyl pyrrolidone, polyethylene glycol,
dextran, hyaluronic acid, or carbomer 940 (polyacrylic acid).

The active ingredient (hydrogel) component of artificial tears provide lubrication (moisture) to
the eye surface. In our opinion, there is no significant difference in the clinical efficacy of different
hydrogels that are used in different artificial tears. In addition, there have been no large scale, masked,
comparative clinical trials to evaluate the wide variety of ocular lubricants. Therefore, the choice of
which artificial tear should be used is based on two features. The first important feature is the type of
preservative used. In general, avoid artificial tears that are preserved with Benzalkonium (BAK). Tears
preserved with newer gentle preservatives like Purite, Polyquad or GenAqua are fine.

The second feature is the presence of "inactive ingredients" that confer unique surface protective
properties to artificial tears. For example, compatible solutes in OPTIVE help surface healing by
Osmoprotection. HP-guar in SYSTANE ULTRA forms a cross linked viscoelastic gel. It has been
suggested that HP-guar preferentially binds to the more dry or damaged areas of the surface epithelial
cells, providing protection for these cells. Hyaluronic acid in BLINK TEARS helps surface healing.

Preservatives are added to increase the shelf life of artificial tears and to facilitate the use
of multi-dose bottles. The more commonly used preservatives are Benzalkonium Chloride (BAK) and
Chlorobutanol. Benzalkoniun Chloride (BAK) can increase the eye surface irritation and disease. The
newer preservatives such as GenAqua (Sodium Perborate), sodium chlorite (Purite) and Polyquad
(Polyquaternium-1) are less damaging to the eye surface than BAC. (Graefes Arch Clin Exp Ophthalmol. 1989;227(2):139-
41, Curr Eye Res. 1991 Jul;10(7):645-56). Purite degrades to chloride ions and water after instillation. GenAqua is
converted to water and oxygen on contact with the tear.

In the patient with mild dry eye, BAK-preserved drops are usually well tolerated when used 4-6
times a day or less. However, patients with moderate to severe dry-eye who use artificial tears
frequently (4 times a day or more) should avoid tear solutions containing Benzalkonium
(BAK) preserved artificial tears. If preserved solutions are used then GenAua or Polyquad containing
tears are better choices. Non-preserved solutions are preferable for treatment of these patients.
However, non-preserved tears are more expensive and are dispensed in single use vials. A recent study
showed that refrigeration of opened preservative free tears in closed zip-lock plastic bags for 12 hours
does not have a significant effect on the solution. Storage of preservative free artificial tears for 12
hours in a refrigerator, therefore seems to be reasonable (Optom Vis Sci 2001;78:37-9).

Despite the addition of hydrogels, artificial tears provide short term relief because of brief
retention time on the eye surface. There are currently two strategies available to increase the retention
time of artificial tears. The more recent development is the introduction of ingredients that have some
bioadhesive properties. Systane uses this strategy. It contains HP-Guar. Once exposed to the eye
surface pH (7.5), HP-Guar in Systane forms a 'sof gel' with increased viscosity and bioadhesive
properties that promote the retention of its two demulcents (polyethylene glycol 400 & polypropylene
glycol). (Curr Eye Res. 2004 Jan;28(1):55-62).
The other strategy to increase the retention time is to make more viscous artificial tears. The
viscous tears are not easily drained out of the eye through the lacrimal outflow system and therefore
have a longer retention time. Viscous artificial tears may cause unacceptable blurry vision in some
individuals. Celluvisc is a 1.0% solution of a high-viscosity Carboxymethyl Cellulose (CMC). Liquigel is
also a 1.0% solution of CMC , however it is blended from a 0.35% high-viscosity and a 0.65% medium-
viscosity CMC. This results in Liquigel being less viscous than Celluvisc. The viscous Celluvisc results in
a moderate amount of blurry vision that gradually subsides. It takes about 24 minutes for the vision
(contrast sensitivity function) to return to baseline values after a drop of Celluvisc is instilled in the eye.
In contrast, after a drop of Liquigel it takes about 13 minutes to return to baseline contrast values. In
patients who find the vision blurring after highly viscous artificial tears like Celluvisc unacceptable, the
shorter duration of blurry vision with Liquigel, (approximately half that of Celluvisc), may be more
acceptable. Higher viscosity tears can cause eye irritation by the crystallization on lids and lashes.(Optom
Vis Sci 2005;82:370-377)

Viscosity Retention time on eye surface


Bicarbonate containing artificial tears have been shown to promote healing in severe dry
eyes. Available bicarbonate containing tears include: Bion Tears, Murine Tears. ( Arch Ophthalmol. 1995
Mar;113(3):371-8, Cornea. 1993 Mar;12(2):115-20)

Prolonging the contact time of artificial tears on the cornea helps. This can be achieved using
a gelling agent such as HP-guar (Systane), or using a viscous eye drop (Celluvisc/Liquigel).( Curr Med Res
Opin. 2005 Feb;21(2):255-60, Curr Eye Res. 2004 Jan;28(1):55-62)

Non preserved drops are the best. However if preserved eyedrops are to be used, then newer
preservatives like GenAqua (Genteal Tears) are preferable to Benzalkonium chloride (BAC). When
eyedrops containing Benzalkonium chloride (BAC) preservative are used frequently, some patients
develop a condition called 'medicamentosa'. This condition mimics a severely irritated dry eye. The
treatment is to stop the eyedrop and switching to non-preserved eyedrops.

Oil containing eyedrops (Refresh Endura, Soothe) may be added if meibomian gland
dysfunction is present. These eyedrops will replenish the lipid layer of the tear film and prevent tear
evaporation. Warm compresses over closed eyelids for 5 minutes will also replenish the lipid layer.

In severe dry eyes and unresponsive surface disease patients have significant visual
impairment and disability. In such patients the use of autologus serum eye drops has been shown to
help. Natural human tears contain many growth factors, antibodies etc. Since these growth factors are
present in serum, using serum eyedrops may provide the surface healing properties of natural tears.
The major disadvantage of serum treatment is the requirement for blood donation. The active
components of serum are stable for up to 6 months therefore bleeding and serum preparation are
required two to three times a year. A standard method to prepare the serum eyedrops has been
described. Blood banks may help you in preparing serum eyedrops.(Br J Ophthalmol. 2004 May;88(5):647-52, Graefes
Arch Clin Exp Ophthalmol. 2005 Mar 9 )

It is apparent that there is no single artificial tear eyedrop that provides all of the surface
healing strategies (bicarbonate ions, hypotonicity, viscosity, non-preserved). Therefore perhaps it may
be beneficial to try different artificial tears. In our opinion, OPTIVE or SYSTANE ULTRA are reasonable
first choice for mild to moderate dry eyes and BLINK TEARS are reasonable first choice for severe dry
eye with extensive surface disease. If there is significant eyelid disease (Blepharitis or MGD), then in
addition to the above recommended artificial tears, one should use an oil containing artificial tear, either
REFRESH ENDURA or SOOTHE XP. At night use a non-preserved ointment like Refresh PM ointment.
Avoid Lacrilube as it has preservative (chlorbutanol).

Avoid the use of redness relieving eyedrops (naphazoline or tetrahydrozoline eyedrops)

such as Clear Eyes, Murine Plus and Visine and herbals such as witch hazel. Also avoid using Vaseline in
the eye. Avoid aggressive washing of the eye with running water or saline. If there are mucous strands
in the tear film, avoid using your fingers or tissue paper to sweep them out towards the nose by directly
touching the eye surface. This may lead to "Mucous Fishing Syndrome" - a condition wherein the eye is
red, irritated and sore because of constant trauma to the eye surface by patient's finger or tissue paper.

Role of anti-inflammatory therapy in dry eye

Evidence suggests that dry eye may be associated with ocular surface inflammation that may
further compromise tear secretion and exacerbate ocular surface disease and irritation symptoms. It is
reasonable to consider anti-inflammatory therapy for patients using artificial tears who continue to have
clinically detectable ocular surface disease, particularly if inflammatory signs (for example, conjunctival
redness) and irritation symptoms are present.

Among the treatment options, topical corticosteroids appear to have the most rapid onset of
action. They appear to be most appropriate for short-term pulse therapy (2 to 4 weeks). They can be
used concomitantly with Restasis (cyclosporin) eye drops. Restasis may require several weeks to
produce a clinical therapeutic effect and up to 6 months for maximum improvement.