There is a vast world of artificial tears. From mild irritation to severe dry eye, there is no shortage of artificial tears for our patients to choose from. However, as a doctor, it can be difficult to keep up with all the current drops available.
Often, the patients will turn to their eye doctor for advice as they can be overwhelmed by the endless selection in drugstores.
In this article, we’ve created an updated list of the artificial tears on the market to serve as a guide to helping doctors select and recommend various artificial tears in each category, from liquid tears to ointments.
We have also provided an overview of indications and pros/cons for each category of artificial tears to help better your understanding of each type of artificial tear and assist you in choosing the right one for your patient.
Liquid artificial tears
Indications for liquid artificial tears
Liquid artificial tears are most often used to treat mild to moderate dry eye syndrome. They are usually first-line therapy due to ease of application and minimal residual blur. Liquid artificial tears are indicated to be used up to six times a day to help treat dryness.
However, if they are being used more than four times a day, it may be time to switch to a more viscous drop, such as a gel or ointment. Furthermore, if a patient is sensitive to preservatives or has more moderate dry eye, one should consider using preservative-free drops to avoid any adverse reaction from excessive preservatives (i.e., corneal neurotoxicity).
Different brands provide different types of lubrication. For example, eye drops such as Systane are more lipid-based and, therefore, provide a coating over the tear film to help slow tear evaporation and can help with meibomian gland dysfunction. On the contrary, Refresh has less of a lipid formulation that tends to feel lighter and more refreshing (hence the name).
Pros of liquid artificial tears
One of the main advantages of liquid artificial tears is in the name itself, “liquid.” This means less stickiness and less visual blur after instilling the drop. These drops can be used throughout the day as many times as needed.
Also, the application of drops tends to be easier than an ointment, which can be difficult to separate from the tube and disperse on the cornea. Many liquid artificial tears now have preservative-free options, which are healthier for the eye and can be used more frequently without adverse events.
Cons of liquid artificial tears
The main disadvantage to liquid tears is that they only keep the eye lubricated for a short period of time before another drop needs to be reinserted. This can sometimes be cumbersome for people who lead busy lives and forget to bring their drops with them during the day.
In addition, though drops with a vasoconstrictor in the formulation (i.e., Visine, Clear Eyes) appear to help dryness by reducing redness, in reality, they are constricting the blood vessels instead of actually lubricating the eye.
And, as they contain preservatives that can cause corneal neurotoxicity over time. Overusing the wrong drops can be dangerous and further exacerbate dry eye symptoms for patients.
Download the comparative list of artificial tears here
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Comparative List of Artificial Tears
Use this list for quick reference when prescribing artificial tears to patients to identify the best drop for every patient's needs.
Preservative vs. preservative-free artificial tears
When choosing artificial tears, many practitioners are replacing eye drops containing preservatives with preservative-free options due to studies that have found corneal damage and ocular discomfort linked with long-term use of preservative drops.
It had been discovered that benzalkonium chloride (BAK), one of the most common preservatives in artificial tears, was linked to membrane instability resulting from the interactions of lipid components in the cell membrane.1
Furthermore, in some cases, patients reported an increase in ocular symptoms (burning and itchy eyelids), as well as ocular signs (superficial punctate keratitis and conjunctival hyperemia) with preservative drops.2
The impact of preservatives on the ocular surface
On a cellular level, using preservative drops resulted in an increase in inflammatory cells in the conjunctival epithelium, along with a significant decrease in the number of goblet cells in eyes treated with preservative eye drops.3
Preservative-free artificial tears induced significantly less epithelial damage than preservative versions.4 Nasser et al. reported that 97% of patients who were switched to preservative-free artificial tears experienced an improved Ocular Surface Disease Index (OSDI) along with a reduction in superficial punctate keratitis (SPK).5
Choosing a preservative-free eye artificial tear can reduce the potential detrimental effect on the eye and has been shown to improve signs and symptoms of the patient’s dry eye disease. However, if a preservative eye drop is required, alternative preservatives such as Polyquad, polyhexamethylene biguanide (PHMB), and oxidized complexes have been shown to have less disruption on the ocular surface.6
Gel artificial tears
Indications for gel artificial tears
Gel artificial tears are the next preferred choice if liquid artificial tears are not sufficient or are being instilled more than four times a day. They can help those patients with more moderate to severe dry eye or lagophthalmos, helping cover the exposed part of the eye when sleeping.
Pros of gel artificial tears
The great thing about gel tears is that they can be used during the daytime or at nighttime. The greater viscosity in the gel drops means that it will last longer on the cornea and, therefore, does not need to be instilled as often.
However, it is not so viscous that it will leave the vision blurry for more than a minute. They are still instilled with a dropper, which makes it easier than ointment but with a similar level of lubrication.
Cons of gel artificial tears
Most gel drops on the market have preservatives, which can lead to corneal toxicity if overused. Furthermore, many patients do not like the consistency of gel drops as they blur the vision slightly yet still do not provide the same level of relief as ointment.
Oil emulsion drops
Indications for oil emulsion drops
Oil emulsion drops tend to have a milky appearance due to the emulsion that is contained in the drop. The emulsion prevents oil and water from separating and consequently allows a longer and more soothing effect of the drop.
They are often chosen when a regular liquid tear does not provide enough comfort and you want a little extra lubrication.
Pros of oil emulsion drops
They are a nice alternative to regular liquid tears if the clear liquid tears are not providing enough relief for the patient. They are slightly thicker, yet do not have the sticky, blurry feeling of a gel drop.
Cons of oil emulsion drops
The main downside to this type of drop is that some patients are turned off by the milky appearance of the drop. It can sometimes leave a slight residual greasy feeling on the lids, but most patients do not mind enough to stop treatment.
Lastly, gel drops can cause a little blur initially but tend to fade quickly.
Ointments
Indications for ointments
If the patient has tried liquid tears, preservative-free tears, and oil emulsion drops and still suffers from dry eyes, it is time to move to an ointment. Generally, ointment is saved for moderate to severe dry eye patients.
It should also be considered if the cornea demonstrates significant SPK—more than half the cornea. Ointment is also great for lagophthalmos patients to provide protection for their eyes while they sleep.
Pros of ointments
Ointment tends to penetrate the cornea for a longer period, which is why it is better for moderate/severe dry eyes. Often, it only needs to be used once at nighttime due to its thicker formulation.
It can also sometimes be easier for patients to see when applying, which provides assurance that the treatment was instilled in the eye.
Cons of ointments
Ointment will likely cause blurry vision for a long period of time and can cause the eyelids to stick together. Therefore, it is usually only prescribed at nighttime. Due to its thick texture, the patient will likely have to clean their eyelids in the morning.
Furthermore, it can be harder for patients with poor dexterity to apply the ointment, and they may need help from a relative, friend, or caretaker
Check out and download the comparative list of artificial tears!
Contact lens drops
Indications for contact lens drops
Contact lens drops are used for patients who tend to get dry eyes when wearing contact lenses or need a boost of moisture throughout the day.
Pros of contact lens drops
This drop can help rewet the contact lens, allowing the patient to be in the contact lens longer during the daytime. Furthermore, the patient does not have to remove the contact lens when instilling the drop since its formulation is meant to work the material in the lens.
Cons of contact lens drops
It helps to rewet the contact lens, but it may not be able to penetrate the cornea and, therefore, only lasts for a short duration. Sometimes, the drop can affect the vision longer when the contact lens is in, and it may take a minute for the contact lens to fall back into proper place.
As a result, the drop should only be instilled when the patient is sitting down.
Beware of homeopathic drops
This section is only included to bring attention to eye doctors that there are artificial tears sold over-the-counter (OTC) labeled as homeopathic. Patients may be inclined to buy homeopathic artificial tears in hopes of using medication that is “healthier” for the eyes and free from harmful chemicals.
Plant-based ingredients like chamomile, euphrasia, and calendula are commonly used in these homeopathic eye drops. In this instance, the ingredients in these eye drops have no scientific support and may harm the eye more than help it.
If you identify a patient who is using a homeopathic dry eye drop, please have them discontinue immediately and educate them on the importance of only using scientifically researched and proven artificial tears.
MIEBO
MIEBO (Bausch + Lomb) is a brand new, first-in-class dry eye drop that helps to treat signs and symptoms of dry eye disease mainly associated with meibomian gland dysfunction. It was recently FDA-approved in May of 2023 as a treatment targeting tear film evaporation.
In the phase 3 studies, MIEBO showed a significant improvement in both corneal staining and eye dryness visual analog scale (VAS) in 8 weeks and relief of dry eye symptoms as early as 15 days.7,8
It is composed of 100% perfluorohexyloctane, which helps to stabilize the tear film by interacting with the lipophilic tear layer and forming a film-air interface to prevent evaporation.
The drop is a non-aqueous liquid, which prevents bacterial growth, and therefore no preservatives are needed. MIEBO is set to launch by the end of 2023 and will be available by prescription.
In the news: Recalled artificial tears
News recently broke in May 2023 that three artificial tears, EzriCare Artificial Tears Lubricant Eye Drops, Delsam Pharma Artificial Tears Lubricant Eye Drops, and Delsam Pharma Artificial Eye Ointment, were recalled due to bacterial contamination resulting in numerous eye infections, blindness, and even a few deaths.9
After these reports, the FDA began investigating numerous eye drop companies for proper manufacturing and packaging of products. This led to nearly 27 OTC eye drops across nine companies voluntarily recalling their products after their main manufacturing plant, Kilitch Health India, was flagged by the FDA for unsanitary conditions.9
Companies included CVS Health, Cardinal Health (Leader and Rugby), Rite Aid, Target Up & Up, Velocity Pharma, and Walmart. Amazon was also forced to recall seven eye drops available for purchase on its website in late November 2023.
This incident not only highlights the importance of ONLY using artificial tears recommended by an eyecare provider, but also that preservative-free eye drops are only better if they are in single-use vials or specially designed bottles that prevent bacterial infection.9
Conclusion
It is advantageous to have a few drops from each category that you are familiar with and you know works with most patients. It also helps to provide samples in-office as the patient is more likely to continue with your recommended drop.
Remember to start with the least invasive treatment, such as a liquid tear, and move to more viscous options, such as an ointment, when needed.
Lastly, as highlighted by the 2023 artificial tear recall, it is imperative to educate patients about the importance of only using doctor-approved eye drops in order to prevent a potentially sight-threatening incident.
