There is a vast world of artificial tears
. From mild irritation to severe dry eye, there is no shortage of artificial tears to choose from. However, as a doctor it can be difficult to keep up on 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. That is why we have created a revamped list of the artificial tears on the market. It can serve as a guide to helping doctors select 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 better help your understanding of each type of artificial tear and assist you in choosing the right artificial tear for your patient.
The following list represents the opinions of the author and not Eyes On Eyecare®. For more information on this topic, please check out our other ocular surface content!
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 such as 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 about liquid artificial tears is in the name itself “liquid”. This means less stickiness and less 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.
Furthermore, overusing a drop, such as Visine® or Clear Eyes®, that has a vasoconstrictor in the formulation appears as though it is helping the dryness by reducing eye redness
. In reality, however, it is not actually lubricating the eye but just constricting the blood vessels. This can be dangerous, as patients could potentially overuse them and they contain preservatives that can cause corneal neurotoxicity overtime.
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This extensive list covers many of the current products on the market; however, with new innovations in artificial tears occurring regularly, we realize some products may not yet be mentioned. If you notice a missing product, please feel free to reach out to us at firstname.lastname@example.org
Preservative vs. preservative-free artificial tears
When choosing artificial tears, many practitioners are replacing eye drops containing preservatives with preservative-free eye drops due to studies that have found corneal damage
and ocular discomfort linked with long-term use of preservative drops.
In a study by Freeman et al. 2009, they found that BAK (benzalkonium chloride), 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, Pisella et al. 2002 found that patients reported an increase of ocular symptoms
(burning and itchy eyelids, as well as ocular signs including superficial punctate keratitis and conjunctival hyperemia) with preservative drops.2
On a cellular level, Sherwood et al. 1989 discovered 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
On the other hand, Berdy et al. 1992 found that preservative-free artificial tears induced significantly less epithelial damage than preservative versions.4 Furthermore, Nasser et al. 2018 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.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 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 to help cover the exposed part of the eye when sleeping.
Pros of gel artificial tears
The great thing about gel tears is that it 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 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 therefore allows a longer and more soothing effect of the drop. They can be more helpful in patients with a strong evaporative component, and are often chosen when a regular liquid tear does not provide enough comfort and you want a little extra lubrication
Pros of oil emulsion artificial tear 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 artificial tear 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.
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If the patient has tried liquid tears, preservative-free tears, and oil emulsion drops and still suffers from dry eyes it might be time to move to an ointment. Ointment is often prescribed for moderate to severe dry eye patients and OSD cases that are refractory to preservative-free tears. 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 ointment for dry eye
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 ointment for dry eye
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 may need help from a relative or friend.
Contact Lens Drops
Pros of contact lens drops
This drop can help re-wet 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 re-wet the contact lens but it may not be able to penetrate the cornea and therefore only last for a short duration. Also sometimes the drop can affect the vision longer when the contact lens is in and may take a minute for the contact lens to fall back into the proper place. Therefore the drop should only be instilled when the patient is sitting down.
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 than buying a generic in-store.
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.
“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.”
Also talk to your patient and discuss which drop would be best for their lifestyle. With all the options available, there is a drop for everyone.
- Freeman PD, Kahook MY. Preservatives in topical ophthalmic medications: historical and clinical perspectives. Expert Rev Ophthalmol. 2009;4(1):59–64. doi:10.1586/17469822.214.171.124
- Pisella PJ, Pouliquen P,Baudouin C. Prevalence of ocular symptoms and signs with preserved and preservative free glaucoma medication. Br J Ophthalmol. 2002;86(4):418–423. doi:10.1136/bjo.86.4.418
- Sherwood MB, Grierson I, Millar L, Hitchings RA. Long-term morphologic effects of antiglaucoma drugs on the conjunctiva and Tenon’s capsule in glaucomatous patients. Ophthalmology. 1989;96 (3):327–335.
- Berdy GJ, Abelson MB, Smith LM, George MA. Preservative-free artificial tear preparations. Assessment of corneal epithelial toxic effects. Arch Ophthalmol. 1992;110(4):528–532. doi:10.1001/archopht.1992.01080160106043.
- Nasser L, Rozycka M, Gomez Rendon G, Navas A. Real-life results of switching from preserved to preservative-free artificial tears containing hyaluronate in patients with dry eye disease. Clin Ophthalmol. 2018;12:1519–1525. doi:10.2147/OPTH.S160053
- Walsh K, Jones L. The use of preservatives in dry eye drops. Clin Ophthalmol. 2019 Aug 1;13:1409-1425. doi: 10.2147/OPTH.S211611. PMID: 31447543; PMCID: PMC6682755.