EyeWorld Asia-Pacific June 2014 Issue

June 2014 61 EWAP PHARMACEUTICALS “Preservatives are fine for short- term use,” Dr. Sheppard said. He pointed to antibiotic drops, which may be taken for a brief period, as a case where preservatives are not only non-problematic, but may provide a synergistic antimicrobial effect. But he stressed that in dry eye and glaucoma, use of chronic preservatives has a cumulative effect. He doesn’t recommend any tears with chemical preservatives, although he does sometimes suggest those with the vanishing alternative, which change their character from antimicrobial to benign tear electrolytes. “I don’t see any reason when we have these good products on the market to use a tear with chemical preservatives in it,” Dr. Sheppard said. For routine patients he relies on tears with vanishing preservatives. Even younger patients who would be more resistant to issues of surface damage are often at risk with preservatives since many wear contact lenses, which may prolong preservative contact time with the ocular surface. In addition to the eye being relatively hypoxic in such cases, the contact lens itself may compound the problem. “The tears and therefore the preservatives will become trapped underneath the contact lens and you’ve got a physiologically sustained release delivery situation,” Dr. Sheppard said. When it comes to more advanced dry eye cases, Dr. Sheppard advises patients to use completely preservative-free tears only. Christopher J. Rapuano, MD , chief of the cornea service, Wills Eye Hospital, Philadelphia, agreed that those with particularly compromised ocular surfaces should avoid preservatives. “The more compromised the ocular surface, whether it’s damage from dry eye, blepharitis, chemical burns, or whatever, the less it tolerates preservatives,” Dr. Rapuano said. Also, he said it’s important to keep in mind the total amount of preservatives that get into the eye each day. If patients’ eyes are pretty healthy and they’re using drops just a few times a day, this is not a big problem, he observed. “But if their eyes are somewhat compromised and they’re on tears three or four times a day it may become a problem,” Dr. Rapuano said. “If their eyes are somewhat compromised and they’re on tears 10 times a day, that is potentially a big problem.” In addition, he said it’s not just the amount of preserved tears to be concerned about but also factors such as preserved glaucoma medications, which are also taken chronically. “If they’re on three glaucoma medications and each of those medications has a preservative in it, then you’ve got to add that to the amount of preservatives that they’re getting with the tears,” Dr. Rapuano said. He switches such patients to preservative-free tears and finds that their eyes often do much better. “The downside of preservative- free tears is that they’re more expensive and they’re less convenient,” he said. With this in mind, Dr. Rapuano tells patients when possible to use one vial for the entire day instead of throwing the vial away after one use. Meanwhile, not everyone thinks that the preservative-free approach is necessary. Robert A. Latkany, MD , associate professor, New York Eye and Ear Infirmary, New York, NY, U.S., views these as essentially hype. “For the last decade or so, there has been a lot of talk on artificial tears, and I am now fairly convinced that there is not a whole lot of merit to the claim that preservatives are damaging to the surface of the eye,” Dr. Latkany said. In his dry eye practice, he has had many patients who have had reactions to the preservative-free tears. Dr. Latkany thinks this may be some sort of allergic reaction. He has not, however, seen anyone who has had a reaction to the preservative itself. “How many people have I seen in the last 15 years who had what appeared to be a reaction to the preservative found in the artificial tear drop—zero,” he said. “It’s a sensitive population—sensitive population patients have reactions to chemicals you put in their eyes. It doesn’t necessarily mean it’s the BAK.” It’s very expensive to use preservative-free drops. “It could be hundreds of dollars a year for patients over the price of a preserved bottle,” Dr. Latkany said. His goal is to get patients off of tears altogether. “I’ll dig deep and try to find out where this inflammation is coming from,” he said. Dr. de Luise acknowledges the added expense but views the preservative-free option as necessary for all but the very mild dry eye patient. “There are no magic bullets—dry eye disease is a diagnosis that is often made in a patient’s 30s or 40s that is chronic and may get worse as the patient gets older,” he said. He urged practitioners to take the time and talk to patients about this. “Say, ‘This is a lifetime disease, you’re not going to go blind, but I recommend that you use single- dose drops as opposed to those with preservatives,’” Dr. de Luise said. “They’ll spend a bit more but they’ll be better served by medicines and drops that are more soothing to the surface.” EWAP Editors’ note: Dr. de Luise has no financial interests related to this article. Dr. Latkany has no financial interests related to this article. Dr. Sheppard has financial interests with AbbVie (North Chicago), Alcon, Allergan, Bausch + Lomb (Rochester, NY, U.S.), TearScience (Morrisville, NC, U.S.), TearLab (San Diego, Calif., U.S.), and Nicox (Sophia Antipolis, France). Dr. Rapuano has financial interests with Allergan, Bausch + Lomb, BioTissue (Doral, Fla., U.S.), Nicox, TearLab, and TearScience. Contact information de Luise : vdeluisemd@gmail.com Latkany : relief@dryeyedoctor.com Sheppard : docshep@hotmail.com Rapuano : cjrapuano@willseye.org