50 EyeWorld Asia-Pacific | March 2025 There are many choices to address this, Dr. Sheppard said. You can use artificial tears for dry eye, and most brands have single-dose dispenser options that allow for preservative-free preparation. There’s also a growing menu of multidose, preservative-free dry eye tear replacements for chronic use. The tears that patients will most likely choose over the counter are less likely to be preservative-free and more likely to be store brand, which are produced in the most cost-effective manner with the least efficacious but still FDA acceptable ingredients, Dr. Sheppard said. The patient, when ill-advised and self-directed, will most likely pick an inferior product based on store name brand promotion and eye level display. Therefore, it is incumbent upon eyecare practitioners to provide the education to make patients with chronic ocular surface disease aware of the relative disadvantages of over-the-counter medications and the need to have a proper diagnosis from an eyecare professional. Virtually all prescription medications for dry eye are preservative-free, except Eysuvis, he said. Dr. Pflugfelder said preservative-free formulations are available for certain glaucoma drops (timolol, dorzolamide-timolol, tafluprost, latanoprost). “Typically, the preservative-free formulations are more expensive, and they may not be covered by the patient’s prescription plan,” he said. “Other strategies are to use combination glaucoma drops versus the individual agents. This will decrease the BAK burden.” There are an increasing number of preservative-free options for treatment of glaucoma. Preservative-free steroids are needed, he said. Dr. Sheppard said there are also strategies for keeping drops out of the eye altogether, like punctal occlusion, where a temporary or permanent punctal plug is inserted to conserve tear film production. There’s also an intranasal stimulant, varenicline (Tyrvaya, Viatris), used twice a day to enhance trigeminal afferent production of the tear film, thereby avoiding drops altogether. “We have a tremendous variety of procedures that can be done in the office that enhance the lipid layer of the eyes and reduce ocular discomfort,” Dr. Sheppard added. W. Barry Lee, MD, Cornea Editorial Board member, shared what evolving treatments and techniques in ophthalmology he is excited about: “I am most excited about cultured endothelial cell injections for corneal endothelial diseases. It is estimated that 8 million people are corneal blind, and yet cell injections can treat more than 100 patients from a single donor while avoiding the need for a cornea transplant in those with diseased endothelium. This technology not only has major implications for our country, but on a global level, it could change the world.” About the Physicians Anat Galor, MD, MSPH | Professor of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida | agalor@med.miami.edu Stephen Pflugfelder, MD | Director of the Ocular Surface Center, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas | stevenp@bcm.edu John Sheppard, MD | Senior Founding Partner, Virginia Eye Consultants and EyeCare Partners Practice, Professor of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia | jsheppard@cvphealth.com Relevant Disclosures Galor: Alcon, Bausch + Lomb, Dompe, Novartis, Oculis, Tarsus Pflugfelder: None Sheppard: AbbVie, Alcon, Aldeyra, Bausch + Lomb, Dompe, Glaukos, Imprimis, Kala, Viatris This article originally appeared in the December 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. In terms of glaucoma, Dr. Sheppard said there is a revolution in drop-sparing therapy to lower IOP. He said the most recent option is iDose (Glaukos), a 3-year travoprost sustained-release implant placed into the angle. There is a shorter-acting Durysta implant (AbbVie) using bimatoprost that can be placed into the anterior chamber at the slit lamp in the office. By far, the most common intervention has been SLT, which is Dr. Sheppard’s first choice for any glaucoma patient. It’s extremely safe, and the treatment effect endures 1–5 years, he said. He added that there are still some glaucoma medications that are available only with preservatives, but companies are producing preservative-free glaucoma medications, like Iyuzeh (Thea), a preservative-free latanoprost. Another solution to glaucoma and dry eye medications with preservatives is through a compounding pharmacy, Dr. Sheppard said, noting that Imprimis and Ocular Science produce a wide variety of medications. “We use their services for combination glaucoma drops,” he said. The glaucoma drop may be preservative free or preserved and contain three medications. It’s not FDA approved, but more and more patients seem to benefit from this approach. Dr. Sheppard thinks the advantages of preservativefree therapy for chronic disease far outweigh the inconvenience. Unfortunately, insurance companies and third-party payers generally tier the preservativefree medications despite FDA approval far above the universally preserved generic preparation, and third-party payers never pay for compounded medications, he said. CORNEA
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