A (sadly) unavoidable review of OTC eye drops

Yes, I am really going to write a column on over-the-counter drops for dry eye disease.

This is going to take at least twice as long to write as any other column. You know, because I have to type it using only one hand while I hold my nose with the other.

We all know that the stuff filling up the eye care counter at CVS, Walgreens, and all of the other -Marts, -Cos and -Aids offers at best short-term palliation of some of the symptoms your patients are suffering. This will not be any kind of exhaustive review, mind you. Nope. More like exhausting. For me.

Do you have any idea how many OTC drops there are out there?

So, why bother? And why bother now? A couple of reasons. We always ask our patients if they take any eye drops. This is a great screening tool. It is my contention that every single patient taking an OTC eye drop has dry eye disease (DED), no matter what they think they are treating. I have yet to have this conjecture disproven.

Recently, we have all been asked about people getting infections from their artificial tears. The EzriCare and Delsam Pharma artificial tears (Global Pharma Healthcare) debacle, in which more than 60 unfortunate souls got a Pseudomonas infection, sure got a ton of press; we should be able to discuss the fact that this was caused by a fringe product that arguably none of us had ever heard of before the FDA recall. Several of my colleagues have noted that they have glaucoma patients who stopped all of their medications, fearful that all drops were now dangerous.

At least three people have died from these infections, adding EzriCare and Delsam Pharma tears to the very short list of eye drops responsible for at least one death.

One final reason to do this kind of review was driven home this week in the office after I had completed a short DED follow-up visit. Basking in the goodwill engendered by improving my patient's symptoms without resorting to a single prescription medication, I realized that I had created an OTC monster. Having bested (for the time being) dry eye with OTC and other physical treatments, my patient was now of the mind that all of their remaining issues could likewise be dispensed with an inexpensive OTC option. "Well, what about my cataracts? What do you think about ‘Can-C’ drops to cure my cataracts?" Naturally, I had no idea what she was talking about.

Knowledge is power, even if it is only the power to disabuse your patients of the all-powerful OTC marketplace's ability to "cure" stuff.

Where shall we start, then? I would love to never discuss OTC tears, to never hear those words uttered anywhere in my zip code, let alone my personal space. I try to convince all of my early DED patients to use the nasal spray Tyrvaya (varenicline solution 0.03 mg, Oyster Point Pharma); it is terrific as a first-line treatment. Sadly, my success rate in the face of the OTC marketing juggernaut is as abysmal as you might imagine. I do have a red line that I refuse to allow my patients to cross (although they all too often ignore me): no OTC artificial tears that contain a preservative. I mean, come on now, this is just common sense, right? The ocular surface has hoisted a white flag. Why continue the assault with BAK bombs?

This rule knocks out at least 75% of the options available. Two simple tests can then be used to further winnow down the choices. Do you test for tear osmolarity? There really is no excuse not to do so anymore. The successor company to TearLab, Trukera, has brought a new portable handheld unit that can test both eyes on the spot, rendering results in roughly 45 seconds. Reimbursement for the test almost always covers both disposables (chips) and the cost of the instrument. If the tear osmolarity is high, your job is super easy. Only three major tears are hypoosmotic: TheraTears (Prestige Consumer Healthcare), Hypo Tears (Novartis) and, my absolute favorite, Blink Tears (Johnson & Johnson Vision) (more below).

Three choices. Barely broke a sweat thinking about that.

You do the other test while using the slit lamp: tear film breakup time. Place fluorescein dye in the inferior fornix. Ask the patient to blink several times and then hold their eyes open. Count. Like "one, one thousand; two, one thousand," etc. As soon as you see a break in the tear film, a dark spot in the dye, you have established the tear film breakup time. Normal is 8 to 10 seconds. Anything less is abnormal. If the tear film breakup time is abnormal, certainly if it is less than 6 seconds, you should use one of the oil-based artificial tears, of which there are four nonpreserved options: Refresh Optive Mega-3 and Refresh Optive Advanced (both Allergan), Optase MGD Advanced (Scope) and Retaine MGD (OcuSoft).

Only four choices this time. Piece of cake, huh?

Not so fast there, Bucky. All of these are more expensive than other options on the board. Your Apple phone-toting, Rolex-bedazzled patient shod in vintage Airs is going to give you a load of you-know-what because they have a brother/cousin/neighbor/pen pal who is doing just fine with XYZ, and it costs only $3.49 a bottle. Or you managed to get them to try one of the nonpreserved options, and they hated it. Because that is how they describe it, isn't it? It is not that they just failed to work well enough — taking those drops just killed them. Now what?

Only 300 choices on the table now. See? Exhausting. Stick to your nonpreserved guns if you can. Remember my favorite above, Blink Tears? It contains hyaluronate, a version of hyaluronic acid. Lots of tears contain this now, including iVizia (Théa Pharmaceuticals) and Systane Hydration (Alcon). Make them work for it a bit by asking them to look for the least expensive drop that contains either hyaluronate or hyaluronic acid. You and I both know that they will give up after looking at no more than two choices, but at least you will have them in the middle of the branded tear section where Alcon, Allergan and Bausch + Lomb drops live. If your patient ends up with a Systane, Refresh Optive or Biotrue (Bausch + Lomb) product, at least they will not be harming themselves.

No deaths reported for these drops, at least not yet.

A couple of parting notes before I take a nap. No worries with the mentholated thing. You know, Rohto Tears and Rohto Jolt (Mentholatum), among others. Some folks just like that "cool burn" feeling. "I can feel it working!" Whatever. Eventually, they need something more real-ish. Contact lens wearers can use pretty much any non-oil-based tear without removing their contacts, but be careful to not use one of the hypotonics with contacts. They cause the lens to dehydrate and "suck on," making removal of the contact a potentially hazardous experience.

Incomplete resolution of symptoms with or without prescription medication is an issue. If you wish to add some sort of lubricant in these situations, I have found iVizia (with trehalose and povidone) and FreshKote (high osmolality to draw excess fluid out to distressed surface epithelial cells) (Eyevance Pharmaceuticals) to be helpful enough in these circumstances to give them a try. They are as close to a "real medicine" for DED as you will find OTC.

And with that, I cry "uncle." I have barely scratched the surface of OTC Land, and I am officially exhausted. Maybe we should just put our patients on a subscription service for OTC products like Myze and call it a day. We all might sleep better.

Editor's note: This article was updated on May 31, 2023, to correct a company name.