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Mastering Tear Supplements
Charles N. S. Soparkar, M.D., Ph.D.
Mirwat S. Sami, M.D.
James R. Patrinely, M.D

Every eye requires regular lubrication, and inadequate lubrication, called "dry eye disease" (DED) may cause anything from mild eye irritation to permanent vision loss. Unfortunately, most people with Benign Essential Blepharospasm (BEB) have some degree of DED. Whether DED promotes BEB, BEB causes DED, or BEB treatment is responsible for DED is often debated, and the reality is that probably all three are true.

It is estimated that somewhere between 4.5 to 25 million U.S. adults suffer from "dry eye disease" (DED) and use tear supplements on a frequent, if not daily, basis. That's a lot of use and a lot of potential industry revenue, considering the relative sizeable profit margin on these products, so it's not surprising that many supplements have come to market, and more seem to arrive each month. With literally hundreds of options available in the supermarket, pharmacy, and internet, which is the right choice?

The following step-wise approach should help you choose the right tear supplement and the right frequency of use for your specific needs.

STEP 1: UNDERSTAND WHAT TEAR SUPPLEMENTS/ LUBRICANTS ARE AND WHAT THEY ARE NOT

Tear supplements are meant to lubricate the eye, nothing else! Drops available over-the-counter without prescription designed and advertised to "take the red out" are NOT tear supplements and should generally NOT be used without the explicit direction of an eye doctor. If you are having a"red" or irritated eye, the cause of the inflammation needs to be determined and managed.

Shrinking the blood vessels on the surface of the eye does NOT treat the underlying cause of the"red eye," and using such drops can be both dangerous for the eye and physiologically addicting.

With rare exceptions, prescription eye drops are NOT tear supplements. Restasis, appropriate for a particular type of "dry eye" problem, is a chemotherapy drug, NOT an eye lubricant.

A tear supplement is NOT an eye rinse or eye wash. Modern tear supplements are designed to bind to the surface of the eye and are not most appropriate to rinse out allergens, eye irritants, or even other thicker tear supplements used over night. People who have"posterior lid margin disease blepharitis", "meibomitis", "sebaceous hyperplasia", or "ocular rosacea"; have been instructed to perform warm compresses to melt or thin the oil component of their natural tears; and in the first few weeks of treatment may wish to use an EYE RINSE or EYE WASH to rinse out the"toxic tear" components of their own tears BEFORE using a tear supplement.

STEP 2: UNDERSTAND WHAT IS IN A TEAR SUPPLEMENT/LUBRICANT

There are four important components of modern tear supplements: the preservative, the type of gel, the concentration of the gel, and other "protective" factors.

I. Preservative
    Most multi-use eye drop and eye ointment lubricants have a preservative in them to prevent bacterial growth and eye contamination. If a tear supplement or lubricant causes eye burning, itching, or irritation, most of the time it is the preservative which is to blame. Thus, when choosing another lubricant, search for one without the same preservative. The most common preservatives are:
  • Benzalkonium Choloride
  • Oxyborate compounds
  • Polyquad
  • Purite
  • Sodium Perborate
  • Sorbic Acid
  • Chlorobutanol
  • Polyquaternium
  • Polyhexamethylene Biguanide
  • Sodium Chlorite
  • Sodium Silver Chloride

Preservative-free lubricating drops and ointments are available, and generally the most widely tolerated, but they also tend to be the most expensive, due to extra storage and packaging costs.

II. Gel Type

Broadly speaking, the "gel" is the material that allows the supplement to stay on the eye longer than just water and is the most important component of an eye lubricant. Some gels may be more or less comfortable for different people. Industry has recognized this and many companies make a whole line of supplements containing a wide range of different gels. Most supplements don't contain a mixture of different gel types, but some people find that using two or three supplements containing different gels at the same time is most effective.

Some of the more common supplements/lubricants available are organized below by the type of gel they contain. The lubricants commonly mentioned by our patients as being favorites are marked with an (*).

  • Carboxy Methyl Cellulose (CMC) - Based
    Optive*, Refresh Liquigel, Refresh Tears, Thera Tears*
  • Glycerin - Based
    Advanced Eye Relief, Computer Eye Drops, Moisture Eyes, Optive*, Similasan Dry Eye*, Soothe*, Tears Natural Forte
  • Hydroxypropyl Methylcellulose (HPMC) - Based Bion Tears*, Genteal*, Genteal Mild, Tears Natural II, Tears Natural Free, Tears Natural Forte
  • Oil - Based
    Refresh Optive Advanced Sensitive*, Soothe XP Emollient Eye Drops*, Retaine MGD*, Systane Balance*
  • Polyethylene Glycol - Based
    Blink Tears*, Systane, Systane Ultra*
  • Polyvinyl Alcohol - Based
    Akwa Tears, Hypotears, Murine Tears,Tears Again
III. gel concentration / Percentage

The higher the gel concentration or percentage, the longer the supplement will protect the eye, but the more likely it is to temporarily blur vision as well. For example, a 0.6% glycerin drop will probably last longer and create more blur than a 0.2% glycerin drop. Mixing supplements of different gel percentages by using them one right after the other is another option, creating a new gel percentage that is otherwise not commercially available. For example, a 0.6% gel drop may be put in the eye followed by a drop containing a 0.2% gel to create an approximate 0.4% gel lubricant. When mixing gels of different concentrations, always put the thicker gel drop in first.

Some of the thickest gels/ointments best for night time use include: Genteal Gel, Lacri-lube ointment, Refresh PM ointment, Tears Again Night and Day Gel, Tears Naturale PM ointment, Duralube ointment, and Puralube ointment. Even Vaseline may be used in people who have no reaction to petroleum jelly and do not mind the arduous eye rinsing in the morning.

IV. Other Protective factors

Some manufactures add ingredients to their lubricants, which they believe confer greater comfort and stability. Examples include Hyaluroinc acid in Blink Tears, hyper-osmolar salts in Optive, hypo- osmolar salts in Hypotears or Akwa Tears, and HP-guar in Systane Ultra. The benefits of such"protective"factors is mostly personal preference and not necessarily substantiated by study.

STEP 3: CHOOSE A TEAR SUPPLEMENT/LUBRICANT

Select a tear supplement. One of the * choices above may be a reasonable starting choice.

If eye irritation (such as itching or burning) is experienced, the preservative is the most likely culprit and choosing a supplement containing another preservative or no preservative (preservative- free) is a reasonable next step.

If the tear supplement feels gritty, slimy, or leaves a"sticky residue," choose a supplement with a different gel. It is important to distinguish between an irritation, which is likely caused by the preservative, and an awareness or annoying feeling, which is most likely caused by the type of gel.

If the tear supplement is too thin, requiring too frequent application, or too thick, blurring the vision unduly, then selecting another supplement with the same gel but a different gel concentration may be appropriate. Remember, the higher the gel concentration, the longer the supplement lasts, but the more likely it is to cause blurry vision.

Supplements of different thickness may be applied to the two eyes at the same time, or the same supplement may be applied to both eyes at different times. Both approaches may avoid prolonged blurring of both eyes simultaneously. Finally, remember that supplements of different gel concentrations may be combined by rapid sequential instillation to create unique gel concentrations.

STEP 4: DETERMINE WHEN AND HOW OFTEN TO USE TEAR SUPPLEMENTS

If the eyes are not dry or irritated in the middle of the night or upon awakening, a tear supplement at bedtime is probably not necessary. If a supplement is needed, a thick gel is probably best. Avoiding sleeping directly under a ceiling fan or heating vent is often useful.

Following a timed schedule of tear supplementation (such as using one drop every hour) is not nearly as useful as "activity-based" use. For example, activities such as applying makeup, reading, working at the computer, watching TV or a movie, and driving require visual concentration and in most people decrease the natural blink rate by at least 3 fold. Decreased blinking means decreased eye lubrication, and use of tear supplements before and during such activities is often helpful. Any factor which increases the rate of natural tear evaporation (such as stepping out into a brisk wind, cold weather, indoor heating) will require more frequent tear supplementation.

Once the eyes have dried out and become irritated, tear supplementation is less effective at providing comfort. So, it is useful to identify eye-drying factors and use the tear supplements BEFORE exposure to such drying influences is desirable.

Excessive tearing may be the reaction of the eyes to severe drying. Using a tear supplement BEFORE engaging in activities which regularly lead to excessive tearing may resolve this symptom. Other common"dry eye"symptoms include burning, gritty feeling, eyelid heaviness, and eye fatigue.

Most tear supplements may be used as often as desired. Slow, frequent blinking can be just as effective for many people as the use of tear supplements.

An excellent reference for determining the composition of many additional tear supplements is the following link:
http://www.dryeyezone.com/encyclopedia/lubricants.html


Originally published in Benign Essential Blepharospasm Research Foundation Newsletter, Volume 33, Number 3, pages 6-7 (2014)

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