ocular surface & dry eye
Pharmaceutical Corner
Assessing artificial tears

More options and better-informed patients

Gone are the days when dry eye patients were given samples of different artificial tears and asked to return for a follow up.
“It’s no longer a simple matter of giving people a grab bag of artificial tears and saying, ‘Choose the one you like,’” said Michael A. Lemp, M.D., clinical professor, Georgetown and George Washington universities, Washington, D.C. There’s an increased burden on clinicians to match increasing sophisticated artificial tears to the specific dry eye problem a given patient might have, he said.
John D. Sheppard, M.D., professor of ophthalmology, microbiology and immunology, Eastern Virginia Medical School, Norfolk, Va., believes that choosing artificial tears nowadays requires a scientific approach and good patient compliance.
Dry eye artificial tear products are not the only more sophisticated factor nowadays; patients are increasingly better educated about their dry eye condition, believes Rebecca Petris, founder, Dry Eye Company, Silverdale, Wash. Ms. Petris’s company provides dry eye guidance to patients, much of it through the company’s Web sites. She often sees on her Web site “hypereducated consumers” who are reading labels closely. “In the last year or two, more consumers have paid attention to active ingredients,” she said. Some may say they are allergic to ingredients in certain tears; others methodically use one tear product after another to find the right one.
At the same time, the economy is forcing patients who have been laid off or who no longer have health insurance to skimp on dry eye care entirely, Dr. Sheppard said. “They’re going to Wal-Mart and finding the cheapest tear product that’s there, and they’re not getting their one-month prescription to Restasis [cyclosporine ophthalmic emulsion, Allergan, Irvine, Calif.] because they can’t afford it,” he said.
Ms. Petris believes that physicians can play a stronger role in educating patients about the difference between over-the-counter dry eye products. There are patients who think that vasoconstrictors may help their dry eye when it might actually irritate it more, Ms. Petris said. Similarly, Robert Latkany, M.D., founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York, has had patients bring to his office print-outs from the Internet with erroneous information about dry eye treatments.
As the choice for artificial tears expands, more companies compete for a piece of the artificial tear market, leading to confusion in the supermarket’s medicine aisle.

To preserve or not to preserve

Dr. Latkany is a strong proponent of preservative-free tears. “Preservative-free Refresh Plus [Allergan] has been my favorite for years,” he said. “I have people refridgerate it. Some people may be a little sensitive to it, and it’s a little more pricey, but it’s generally well tolerated.” Dr. Latkany also likes the preservative-free versions of Blink (Abbott Medical Optics, Santa Ana, Calif.) and Systane (Alcon, Fort Worth, Texas).
Although he realizes that cost can be a factor in patient selection, he favors preservative-free tears for patients to avoid any irritation from the preservatives. The majority of his patients have more severe forms of dry eye that need more than just artificial tears to combat the condition, hence why he favors the preservative-free versions.
Dr. Sheppard finds that artificial tears with vanishing preservatives are effective for the majority of his patients, although he will start off with preservative-free tears in patients with severe dry eye.
“The single-dose units are more expensive and require greater manual dexterity. They can be tough for patients who also have rheumatoid arthritis. Sometimes, patients with their hurried schedule can’t open the units very well and then poke their eye with the tip,” he said.
Ms. Petris said that more patients seem to favor tears without preservatives or with more mild preservatives, often because their physicians have emphasized the preservative issue.
Dr. Lemp believes that tear preservatives need a closer look because any tear product can disturb the equilibrium in the eye, albeit temporarily. “We’re not sure why this happens. It may be because of the preservatives, or it may be because there is something new in the eye,” he said. Even products with disappearing preservatives may have an effect, he said.

Making the right choices

Ophthalmologists should try and match their patient’s type of dry eye to the appropriate ingredients used in specific tear products, Dr. Lemp said. “Each tear targets a specific dysfunction. For example, if you have evaporative dry eye and meibomian gland dysfunction, you should look for an artificial tear with oils to retard evaporative tear loss, such as Soothe [Bausch & Lomb, Rochester, N.Y.] or Systane Ultra [Alcon],” he said. “If you have a patient with a concentrated tear film, you might want to look at a product like Optive [Allergan], which has a higher osmolarity.”
Many of the companies have tear products specific to contact lens use, longer versus shorter duration, and other factors. However, Dr. Latkany doesn’t find much of a difference between those specific formulations. “If one product was so much better than all the others, then every doctor and patient would be using that drop. That’s just not the case. It’s really trial and error,” he said.
Some patients even report success with homeopathic drops such as those from Similsan (Highlands Ranch, Colo.), Dr. Latkany said. “I don’t know if it’s the placebo effect or because it’s homeopathic.”
Others consider the occasional published studies on artificial tears to assist with their choice. A study published in the February 2009 issue of the American Journal of Ophthalmology reported that patients treated with Vitamin A drops—Viva artificial tears (retinyl palmitate 0.05% and polysorbate 80 1%, Vision Pharmaceuticals, Mitchell, S.D.) had significantly improved dry eye signs and symptoms similar to those in a second study group treated with Restasis. Both groups outperformed a control group of patients treated with another brand of artificial tears. The study authors did not report any related financial interests. Although some ophthalmologists report trouble finding Viva, the drops are sold through the drug store Rite Aid and through general suppliers to pharmacies, according to company reps.
Economic factors may also affect the tear market. While cash-strapped consumers may turn to tears—sometimes the cheapest ones—because they can’t afford prescription medications, Dr. Latkany has actually seen an interesting reverse trend. “Preservative-free tears are 50% to 100% more expensive than the bottle, especially if the patient needs to use a bottle every hour. I’m having patients come in and say that they want punctal plugs,” he said. By having punctal plugs, the right patient can avoid the cost of over-the-counter drops. Other patients are opting for Restasis when it’s covered by their insurance or going for regular allergy shots to rid themselves of dry eye compounded by costly allergy medications, he added.
While Ms. Petris has not observed a wave of patients choosing punctal plugs, she agrees that many are making medication choices based on cost factors more than they did before.

Flooding the future with tears

Despite recent growth in the artificial tear market, the segment is still ripe for unique possibilities.
In countries like Japan, 1% sodium hyaluronate is used as a prescription medicine for dry eye, Dr. Sheppard. In the U.S., sodium hyaluoronate is merely an additive to the tear product Blink. This shows that there are other avenues for artificial tears in the future, he said.
As dry eye awareness grows, physicians and patients alike need better ways to measure the effects of artificial tears, Dr. Lemp said. Ocular staining and long-term stability of the tear film are two measures that need further investigation with the use of artificial tears, he said.
“One good thing with all of these products is that they dilute tears,” Dr. Lemp said. “In many patients, they have pro-inflammatory cytokines that cause inflammatory events. If artificial tears can dilute this, it’s a good thing.”

Editors’ note: Dr. Lemp has financial interests with OcuSense (San Diego). Dr. Sheppard has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), and Inspire Pharmaceuticals (Durham, N.C.), among other ophthalmic companies. Ms. Petris is the founder of Dry Eye Company (Silverdale, Wash.). Dr. Latkany has no financial interests related to his comments.

Contact information

Latkany: 212-689-2020, relief@dryeyedoctor.com
Lemp: 202-338-6424, malemp@lempdc.com
Petris: 877-693-7939, ext. 717, rebecca@dryeyecompany.com
Sheppard: 757-622-2200, docshep@hotmail.com