Tear Substitutes

The most common treatment for dry eyes is tear supplementation. There are a variety of tears available for patients. No one brand of tears is ideal for every patient. The type and frequency of tear supplementation varies depending on several factors:

  • Severity of dry eyes
  • Environmental conditions (temperature and humidity)
  • Medications
  • Activities (such as staring at computer screens)

As the severity of dry eye condition progresses, tear supplementation needs to be more frequent. It is important to realize that there is “no magic number” for the number of times that each patient should use tears each day. If someone lived in a constant environment, like a space ship, with identical environmental conditions each day (temperature, wind and humidity), then a fairly consistent tear regimen could be established. Unfortunately, in the Washington metropolitan region, the weather fluctuates on a regular basis. In the winter and summer, when forced dry heat or air conditioning is needed; tear supplementation needs to be more frequent. The doctors at EDOW usually recommend a range for the frequency of tear supplementation (i.e. 2-4 times/day or 4-6 times/day, etc). We suggest that patients take an active role in adjusting their tear frequency based upon the variables discussed above.

Of equal importance is understanding that tears should be used proactively rather than reactively. If you have a lawn, you do not wait until it turns brown and then water it. You water it so it stays green and healthy. In our hectic world, patients often forget to use their tears on a regular basis. They often wait until their eyes hurt, and then use tears when their eyes hurt. This behavior is repeated all day long. If you wait until your eyes are uncomfortable, the dryness is causing damage and inflammation to the ocular surface. It takes more tears to heal a damaged surface than maintain a healthy surface. Once a patient establishes a regular regimen, the need for tears actually diminishes since the ocular surface is healthier.

Did You Know…

One helpful hint is for patients who use computers all day to place a timer on the compute. This reminds them to use tears on a regular basis

There are a variety of types of tears. They are categorized below:

Preservative Free Tears

Most tear supplements come in a bottle. Once the bottle is opened, there is concern about contamination with microorganism. Bacteria may contaminate and colonize within the tear bottle leading to infection. To minimize the risk of bacteria, preservatives are placed into the tear bottles to eliminate bacterial growth. When tears are used on a frequent basis (greater than 4 times/day), the preservatives placed into the tears bottles can be toxic to the ocular surface.

To avoid this toxic effect, preservative free tears were developed for patients who need to use tears frequently. These tears are delivered from small individual packets. The tear packets can be used for more than once per day; however, they should not be used once open for greater than 12 hours.

Preservative free tears come in a variety of formulations. They contain nutrients to heal and maintain the ocular surface. They may also contain substances to thicken the tear film. Thicker (viscous) tears are helpful in conditions where the tear film is unstable; however, the viscous agents such as methylcellulose can blur vision as well as from a coating on contact lenses.

  • Non-viscous tears: These “thin” tears have minimal viscous agents. Some of the tear brands include: Bion, Refresh, Refresh Plus, Theratears, and Tears Naturale PF.
  • Medium Viscosity tears: These tears contain methyl cellulose (or other thickening agents) as well as electrolytes. Some of the brands include Endura, Refresh Plus, and Theratears.
  • Viscous tears: These include higher concentrations of methylcellulose and are usually limited to eye conditions where the ocular surface is irregular or very unstable. They are also used at bedtime for greater protection while sleeping. Brands include Celluvisc and Occucoat.

Dissolving Preservative Tears

This type of tear product is relatively new. These tear bottles have a special type of preservative that becomes inactive when the tear comes in contact with the environment (either oxygen or light). These types of tears have the benefits of being able to be dosed on a frequent basis (more than 4 times/day) while maintaining the convenience and cost of being dispensed in bottle form.

  • Non-viscous tears: These tears are similar to the preservative free tears. Some of the brands include Refresh and Genteal.
  • Viscous tears: These tears have a higher concentration of gels to thicken and stabilize the tears. Brands include Refresh Liquidgel and Genteal Medium).

Preservative Tears

These types of tear products are available in bottles. This makes them less expensive and convenient. Tears with preservatives should be limited to no more than four times per day. A variety of companies make tears containing preservatives. Some of these brands include Systaine and Tears Naturale II.

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Restasis, the first medication specifically indicated to increase tear production and reduce inflammation was approved by the US FDA last year. Restasis is created from cyclosporine, an anti-inflammatory immunomodulating drug. In clinical trials, 60% of patients produced more tears. There was also clinically significant improvement in patient symptoms and ocular irritation.

Restasis is available as a drop that is used twice a day. The drug takes several months to be fully effective. The doctors at EDOW have had great success with this medication. Dr. Clinch and Dr. Kang has been an invited lecturer to teach other physicians on the clinical applications of the medication.

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Punctal Occlusion

Tears are removed from the ocular surface through a specialized lacrimal drainage system. (See below). There are two drainage systems present in each eye. They are located in the upper and lower lid. The opening to the drainage system is called the puncta. Closing one or both puncta decreases the rate at which tears can drain from the ocular surface. Punctal occlusion can reduce the frequency of tear supplementation as well as improve dry eye symptoms.

There are two methods to close the lacrimal drainage system. The doctors at EDOW perform these procedures on a daily basis.

Punctal Plugs

Plugs made out of a collagen or silicon can be inserted into the drainage system. The procedure is brief (2-3 minutes) and painless. The silicon plugs do not dissolve and can remain in place for years. Punctal plug placement is a reversible procedure. If excessive tearing occurs, the plugs can be removed. Since dry eyes are a medical condition, insurance companies should provide coverage for this service.

Punctal Cautery

The lacrimal drainage system can be permanently closed with heat. The punctal region is first anesthetized; heat is then used to seal the punctal opening. This procedure is brief (2-3 minutes) and performed in our offices on a regular basis. Since dry eyes is a medical condition, insurance companies should provide coverage for this service.

Punctal plug

Punctal plug

Insertion of a punctal plug

Insertion of a
punctal plug

Punctal plug in place

Punctal plug in place

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Oral Supplements

Oral supplements of omega-3 essential fatty acids may be of assistance in managing dry eyes. Daily dietary supplementation has been shown in scientific studies to do the following:

  • improve the oil and aqueous (water) layers of the tears
  • suppress ocular irritation

Omega-3s are essential fatty acids. “Essential” fatty acids means that these chemicals cannot be produced by our body. They must be ingested as part of our diet. The two best sources of omega-3s are dark, oily, cold-water fish, and flaxseed. These essential fatty acids have been established to provide a multitude of health benefits. Surprisingly, up to 83% of Americans may be deficient in omega-3s.

Dietary supplementation with essential fatty acids is available by many companies. Theratears Nutrition and HydroEyes are two brands that have been utilized by the doctors at EDOW.

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