As a primary eyecare provider
, it is important to prescribe specific eye drops
for your patients, even if they are over-the-counter products. This is still just as true today as it was when I first wrote this article in 2018.
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!
Did you complete the exercise recommended back in 2018 to go to your local grocery or drug store and take a stroll down the artificial tear aisle? If not, now is your second chance. Understanding what the patient is affronted with is important to understanding the importance of prescribing OTC products from your chair. Giving written instructions, handouts with the recommended products, or selling the products in the office can be very helpful to ensure the patient gets the correct product(s).
“For those of you who choose not to sell in the office, consider finding the product online and have the patient take a picture with their phone.”
Here is my updated list for the best artificial tears available to us in 2022 for each type of patient need.
Best tears for Meibomian Gland Dysfunction (MGD) patients
Systane Complete (propylene glycol 0.6%)
The same great artificial tear and science of Systane Balance now has advanced nano-droplet technology with HP-Guarㅿ and mineral oil. These improvements form a matrix of protection across the entire ocular surface, and according to Alcon, provides better moisture retention and coverage vs Systane Balance while providing 8 hours of dry eye
Of note, Systane Complete
is not to be used while wearing contact lenses. And of course, MGD should never be treated solely with artificial tears, but as an adjunct for symptomatic relief, Systane Complete can be utilized with success.
ㅿ HP-Guar (hydroxypropyl-guar) is a viscous gelling agent made by treating a water soluble polysaccharide with propylene oxide. In a double-masked, six-week study conducted with eighty-seven dry eye volunteers, the lubricating drop (propylene glycol) with HP-guar performed better than the control (carboxymethylcellulose) in controlling both the signs and symptoms of dry eye
HP-Guar significantly reduced conjunctival staining (p< 0.025) and temporal corneal staining (p<0.024) as well as symptoms of dryness in both the morning and evening.
Test volunteers using the lubrication drop with HP-Guar reported clinically significant lower frequency of foreign body sensation and reported that their eyes were “refreshed longer” compared to the control.2
Best preservative-free tears
Optase Dry Eye Intense Drops (Glycerin 0.2%, Hyaluronate Sodium)
Multi-use, preservative-free bottles are the new preferred method of packaging and application for artificial tears. Optase Dry Eye Intense Drops
’ 10mL bottles employ a one-way valve and a zinc-ion-lined inner cap to prevent contamination. It provides 300 drops of preservative and phosphate free artificial tears that lasts three months after opening. It is important to emphasize, like all drop applications, to avoid touching any part of the bottle to your eyes or lashes and to always securely apply the cap when done using.
Furthermore, this bottle does take a little more squeezing for dispensing of a drop than an average bottle. It is safe to use with contact lenses.
For those patient who still prefer individual vials of preservative-free artificial tears (to stash and store in many different locations and for travel and/or backpacking) Oasis Tears Plus (Glycerin 0.22%) is still a great lubrication drop containing hyaluronic acid and glycerin, similarly to Optase Dry Eye Intense Drops.
Best drop for longer relief and nighttime use
Blink GelTears® (Polyethylene Glycol 400 0.25%)
For those patients who want that extended relief and don’t mind a few minutes of blur after installation, gel drop artificial tears can provide it. Although, I believe they make a better nighttime therapy and are best used right before bed. I usually start with Blink GelTears
for my patients suffering with dryness symptoms starting first thing in the morning. These patients often have a poor lid seal which can quickly and easily be confirmed with a Korb-Blackie lid-seal light test.
To perform, place a transilluminator against the relaxed, closed, outer upper eyelids of semi-reclined patients. For patients with a poor lid seal, light can be seen escaping (see Image 1 below), usually centrally, from the upper lid. These patients were significantly (p < 0.0001) more likely to have symptoms of discomfort upon awakening.3
Tip: Applying an ointment can be a little bit of a mess. You can easily get plastic or silicone mini cosmetic/beauty spatulas that can work-great for application.
Of course, discussing turning off bedroom fans and implementing humidifiers in the bedroom are additional environmental factors you can suggest to patients suffering from morning dryness symptoms or nocturnal lagophthalmos.
Best lubrication method for those who don’t like drops
Optase Dry Eye SPRAY (Glycerin 1%)
For those patients who struggle instilling artificial tears, this preservative-free, lipid-containing, lubrication spray is fast and easy to use. If you think about it, there are some mild “hassles” with instilling an artificial tear. Elderly patients who may have problems holding and manipulating small bottles will benefit from Optase Dry Eye Spray
's larger-than-average 17ml bottle.
Those with neck or back problems may struggle tilting their head far enough back to get an easy window to apply drops without missing multiple times. If you are a frequent user, the time (and tissues to dab away excess tears from larger than necessary drops) adds up. Young children or those with special needs may benefit immensely from an easier application method (and I’m sure their parents and caregivers too). You apply by spraying onto closed eyes from a distance of about 6-10 inches. As you blink it dissipates and spreads over the tear film and provides lubrication.
After my personal use with it, I do find the spray a little intense and react the same way as during air-puff tonometry; with an intense blink and retreat. However, I can say that my eyes felt wonderful after using it. It creates a little cloud of humidity and my eyes feel fresh and moisturized without the flooding of a normal drop.
Choosing the “right” artificial tear can sometimes feel like closing your eyes and throwing a dart at the wall, but the above options have been successful for my patients and are worth recommending and discussing. If nothing else, it will at least deter your patients from reaching for the cheapest “artificial tear,” the dreaded Visine.
It is also worth stating again that artificial tears alone are rarely sufficient as the sole treatment for patients suffering from multifactorial dry eye disease
. Make sure you are discussing all necessary treatments and environmental factors when managing your dry eye patients.
- Systane® Complete Lubricant Eye Drops. SYSTANE® COMPLETE Lubricant Eye Drops | Systane®. (n.d.). Retrieved February 16, 2022, from https://systane.myalcon.com/products/systane-complete/
- Christensen MT, Cohen S, Rinehart J, Akers F, Pemberton B, Bloomenstein M, Lesher M, Kaplan D, Meadows D, Meuse P, Hearn C, Stein JM. Clinical evaluation of an HP-guar gellable lubricant eye drop for the relief of dryness of the eye. Curr Eye Res. 2004 Jan;28(1):55-62. doi: 10.1076/ceyr.126.96.36.19995. PMID: 14704914.
- Blackie CA, Korb DR. A novel lid seal evaluation: the Korb-Blackie light test. Eye Contact Lens. 2015 Mar;41(2):98-100. doi: 10.1097/ICL.0000000000000072. PMID: 25503913.