Table II Comparative chart of artificial tears Preserved Tears
Gels/Ointments
Non-Preserved
Various Preservatives
Refresh Optive Advanced Refresh Optive Fusion Refresh Tears Refresh Ultra Tears Naturale Systane Ultra Systane Balance GenTeal HypoTears Liposic TheraTears Isopto Tears
Refresh Liquigel Tear-Gel GenTeal Gel Systane Gel Lacri-Lube Liposic Gel Tears Naturale PM HypoTears Ointment DuoLube Ointment
Refresh Plus Refresh Celluvisc Refresh Endura Refresh Unit Dose Bion Tears TheraTears Tears Naturale Free Systane Ultra Preservative Free i-drop HYLO Drops / Gel i-drop Pur i-drop Pur Gel
Purite BAK Polyquad Cetrimide Sodium Perborate
Certain artificial tears specifically address lipid tear film deficiencies – emulsion formula. Some have wound healing properties. Gentle, more acceptable preservatives with least disruption to the corneal surface are available.
practitioners may not be able to wholly fix patient’s symptoms, but they can reduce the symptomology and definitely reduce the progression. With episodic cases, said Dr. Avinashi, this is where palliative care is standard. Using artificial tears and hot compresses is very important. Non-ocular considerations are sometimes overlooked for the sake of brevity, to get the patient out of the chair, or to encourage them to buy glasses, versus actually managing their disease. Patients’ medications, diet, level of alcohol consumption, whether or not they smoke, and environmental factors play an enormous role as well. In Vancouver, particularly, there are frequent climate changes, and Dr. Avinashi finds that with the higher pollen count he has a lot more patients with dry eye symptoms visiting his clinic.
ARTIFICIAL TEARS Dr. Avinashi is an avid advocate for tear supplementation. One of his maxims with any product in the realm of dry eye disease treatment is that practitioners should recommend what they sell and sell what they recommend. If optometrists are recommending a product but aren’t selling it, they’re encouraging the concept of patients going elsewhere for what they need and what has been recommended to them. It’s essential to get the staff on board, and to find products that are unique and above the average grade. He recommends first, selling items that patients can’t find in other retail locations; and second, creating more loyalty to one’s practice so that patients aren’t simply seeking out the lowest-cost products at big box stores. The practitioner’s responsibility is not to be cost sensitive to patients, but to provide them the best recommendations, whether it’s an artificial tear, a heat compress mask, a progressive lens, or a contact lens. In his view, optometry is far too conservative in terms of what the patient can and can’t spend. They need to be provided options, but should always be given the best one first.
140
Clinical & Refractive Optometry Quebec 2:4, 2017
There is a plethora of artificial tears (Table II), Dr. Avinashi noted that his view of artificial tears has greatly changed over the last few years. Most patients, roughly 80%, have evaporative dry eye disease, therefore, optometrists should be recommending lipid-based artificial tears. These patients are often consulting with their GPs and pharmacists for recommendations, and they’re using such products as Tears Naturale® 2 (Alcon, Mississauga, ON) and GenTeal® (Novartis, Dorval, QC). Dr. Avinashi regards these as antiquated given that there has been such an evolution in artificial tears and newer, more advanced products are available. When a patient consults with an optometrist, they may not even mention that they have dry eyes, yet they use a small amount of artificial tears. He advises that practitioners take the time to find out what patients are using because sometimes they become complacent about their drops. They aren’t even aware of which product it is and if it’s appropriate for their situation. Inform them that a customized treatment regimen is what they need, more than anything else. Sodium Hyaluronate Dr. Avinashi is a proponent of preservative-free artificial tears. For aqueous deficient dry eyes for which he doesn’t wish to use a lipid-based agent, he opined that if a practitioner isn’t prescribing a product containing sodium hyaluronate, they’re underserving their patient population. In the European market, said Dr. Avinashi, if someone took a poll of every artificial tear that was being offered, 70% of these would contain sodium hyaluronate. A few years ago in Canada, there were only one or two products; now there are perhaps eight, and in the next year or two there are going to be a lot more in the pipeline. Sodium hyaluronate is a polymer that is found in the body’s synovial joints, aqueous humor, many collagen cells, and in the corneal tissue, as well. It’s a natural lubricant and the reason it’s so effective is that it has