Page 1 of 12
`
`Michelle Stephenson, Contributing Editor
`PUBLISHED 4 OCTOBER 2012
`OTC Drops: Telling the
`Tears Apart
`When choosing an over-the-counter artificial
`tear for your dry-eye patient, consider severity
`of disease and form of dry eye.
`
`Artificial tears are a mainstay in the management of dry-
`eye symptoms, and there are numerous over-the-counter
`artificial tear products on the market today. Patients are
`often overwhelmed by the choices and do not understand
`the differences between them. When helping patients
`choose a tear, the most important considerations are the
`underlying cause of the dry eye and how often the patient
`is instilling drops.
`
`“Self-selection of medications is not a good idea,” says
`John Sheppard, MD, professor of ophthalmology,
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`MYLAN - EXHIBIT 1085
`Mylan Pharmaceuticals Inc. et al. v. Allergan, Inc.
`IPR2016-01127, -01128, -01129, -01130, -01131, & -01132
`
`
`
`Michelle Stephenson, Contributing Editor
`PUBLISHED 4 OCTOBER 2012
`OTC Drops: Telling the
`Tears Apart
`When choosing an over-the-counter artificial
`tear for your dry-eye patient, consider severity
`of disease and form of dry eye.
`
`Artificial tears are a mainstay in the management of dry-
`eye symptoms, and there are numerous over-the-counter
`artificial tear products on the market today. Patients are
`often overwhelmed by the choices and do not understand
`the differences between them. When helping patients
`choose a tear, the most important considerations are the
`underlying cause of the dry eye and how often the patient
`is instilling drops.
`
`“Self-selection of medications is not a good idea,” says
`John Sheppard, MD, professor of ophthalmology,
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`MYLAN - EXHIBIT 1085
`Mylan Pharmaceuticals Inc. et al. v. Allergan, Inc.
`IPR2016-01127, -01128, -01129, -01130, -01131, & -01132
`
`
`
`Page 2 of 12
`
`microbiology and molecular biology at Eastern Virginia
`Medical School. “Invariably, when patients bring in their
`drops, they will be the Wal-Mart or Safeway brand of tears,
`which are by far the most inferior tears on the market. Or,
`worse yet, they will use a topical vasoconstrictor like
`Visine, which induces vascular fragility, rebound
`vasodilation and dependence upon the vasoconstrictor to
`maintain a quiet, white-looking eye. Many times, patients
`will present using drops every 30 minutes or every hour,
`and this has a deleterious effect on lifestyle and well-
`being.”
`
`When choosing an artificial tear for patients, experts
`generally consider three questions: Based on disease
`severity and dosing, is the optimum artificial tear for this
`patient preserved or not preserved? Does the patient have
`more of an aqueous deficiency, mixed disease or an
`evaporative form of dry eye? How severe is it?
`
`Preservatives
`
`In recent years, there has been debate about whether the
`preservatives used in artificial tears are safe. While there
`are obvious advantages to the use of preservatives,
`several recent studies have highlighted the toxic effects of
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 3 of 12
`
`benzalkonium chloride. For example, a recent study
`conducted at the University of Illinois at Chicago found that
`topical application of BAK to the eye causes corneal
`neurotoxicity, inflammation and reduced aqueous tear
`production.
`1
`
`Figure 1. Inferior superficial punctate
`
`keratopathy in mild dry eye. (Image
`
`courtesy John Sheppard, MD.)
`In this study on mouse eyes that were topically treated with
`vehicle or BAK (0.01% or 0.1%), BAK-treated corneas had
`significantly reduced nerve fiber density and aqueous tear
`production, and increased inflammatory cell infiltration and
`fluorescein staining. Changes were most significant after
`treatment with 0.1% BAK. Sequential in vivo imaging of
`corneas showed both reversible neurotoxicity
`characterized by axonopathy and recovery and irreversible
`neurotoxicity characterized by nerve degeneration and
`regeneration. Both doses of BAK reduced nerve fiber
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 4 of 12
`
`length; however, the reduction was significantly more with
`the higher dose.
`
`Fortunately, patients with severe dry eye or patients who
`are hypersensitive to preservatives now have excellent
`choices of a totally preservative-free drop, according to Dr.
`Sheppard. “There are good choices from a wide variety of
`manufacturers, and they come in a single-dose unit (SDU)
`with a twist-off cap,” he says. “In theory, you take one
`dose, and you dispose of it. Careful handling of the SDU
`will allow multiple uses because many are re-cappable,
`and as long as you don’t contaminate the tip by touching
`your fingers, eyelids or eyelashes, then it can be reused at
`least over the course of one day. However, I don’t
`recommend that practice to unreliable patients,” he says.
`
`If a patient requires a preservative-free preparation, Dr.
`Sheppard notes that a few good choices are Refresh
`(Allergan), TheraTears, Soothe (Bausch + Lomb) and
`Systane (Alcon). “You can never go wrong with these. It’s
`just a little more expensive and a little more time-
`consuming to apply the drops,” he adds.
`
`Another choice is formulations containing vanishing
`preservatives. The preservatives basically turn into water
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 5 of 12
`
`or a non-toxic chemical when they are exposed to air or
`mix with the tear film. “The first vanishing preservative
`(sodium perchlorate) was introduced in the Genteal brand
`by Novartis, which is still available. Another brand of
`vanishing preservative is sodium chlorite or Purite from
`Allergan, which is found in a wide variety of their products,
`including all of their multi-dose preparations of the Refresh
`Optive brand of tears,” Dr. Sheppard explains.
`
`Robert Latkany, MD, notes that cost can also play a role in
`artificial tear choice. “The preservative-free products can
`be double the cost of the preserved ones,” he says. “There
`have been studies showing that these preservatives are
`destroying the ocular surface, but I think it’s overstated and
`overhyped. If I can save some money for a particular
`patient and have him or her use Refresh Liquigel with a
`disappearing preservative rather than Refresh Celluvisc
`because they are using these products forever, numerous
`times a day, then I will take that into consideration. Many of
`these people see me every two to four weeks, so I can
`monitor the situation. If there is ever an issue with an
`artificial tear product, I pick up on it quickly,” says Dr.
`Latkany, founder of New York Eye and Ear Infirmary’s Dry
`Eye Clinic.
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 6 of 12
`
`The choice between a tear with a preservative and a
`preservative-free tear comes down to the number of drops
`instilled in the eye daily. According to Stephen Pflugfelder,
`MD, director of the Ocular Surface Center at Baylor
`College of Medicine in Houston, it would be best for
`patients who use tears more than four times a day or who
`have severe dry eye to use a preservative-free unit-dose
`artificial tear.
`
`Lipids
`
`Another important approach to providing an excellent over-
`the-counter tear preparation is to attempt to mimic the
`biphasic nature of tears by providing a lipid and an
`aqueous component to the tear, Dr. Sheppard says. “The
`guar in Systane provides an excellent matrix for the
`aqueous component of the tear. Refresh Optive Advance
`as well as Soothe from Bausch + Lomb provide a lipid
`substitute to better stabilize the tear film. Another valuable
`additive to over-the-counter tears is hyaluronic acid, which
`can be found in Blink tears from Abbott,” he explains.
`
`Viscosity
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 7 of 12
`
`Another factor to consider when recommending drops is
`viscosity. Patients with mild dry eye may prefer a watery
`drop, while those with more severe dry eye may prefer a
`thicker drop that stays on the cornea longer.
`
`Figure 2. Moderate stippling of the
`
`corneal surface with fluorescein, as
`
`typically seen in patients with dry eye.
`
`(Image courtesy Jay Pepose, MD, PhD.)
`“For more severe dry-eye patients and for patients who
`have many erosions on their corneal surface, I would
`prefer a thicker, more viscous drop, such as Refresh
`Celluvisc or Systane Ultra preservative-free,” Dr. Latkany
`says. “The problem with the more viscous drops is that
`they tend to blur the vision because they are gooey and
`sticky. They leave more residual foreign particles in the
`eye. As the product sits on the lash, it hardens, forming
`crust. Also, the gooey nature of the drop allows allergens
`and other chemicals to stick to the tear film. However,
`there are also problems with watery drops like Refresh
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 8 of 12
`
`Plus. While I think they are the best drops, I have found
`that they really don’t last much longer than three to four
`minutes. Patients will be putting a lot of drops in their eyes
`if they have to use them every three to four minutes.”
`
`Dr. Pflugfelder agrees that transient blurring can be a
`problem with more viscous drops. “Although the more
`viscous tears may decrease friction in the eye and lubricate
`the eye better, they do come with the side effect of being
`more blurry. In some cases, if someone can’t close his or
`her eye because he or she has Bell’s palsy, and a whole
`section of the inferior cornea is drying out, I definitely would
`recommend a thicker tear or a gel or even an ointment,
`knowing that although it may blur the patient’s vision, it
`would probably protect the eye better. People who have
`good vision and can blink normally don’t tend to like very
`viscous artificial tears. Some people use them at night, but
`you can even have blurred vision for an hour or so after
`you wake up in the morning,” he adds.
`
`Osmolarity
`
`Another differentiating feature among the drops is
`osmolarity. “Some tears have lower osmolarity,” Dr.
`Pflugfelder says. “There are some studies that show that
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 9 of 12
`
`lower osmolarity tears may have a better effect on the
`ocular surface. There are some tears that have ingredients
`that are called osmoprotectants. They are taken up by
`cells, and they blunt the response of the epithelial cells on
`the surface of the eye to high osmolarity in the tears. The
`Optive tears have osmoprotectants; some of those are
`found in sports drinks also because people can lose a lot of
`fluid and their blood may be a higher osmolarity. There is
`pretty good scientific evidence that they do help to protect
`cells.”
`
`For example, a study conducted by Dr. Pflugfelder and his
`colleagues at Baylor found that the osmoprotectants
`L-carnitine and erythritol, alone or in combination, protect
`against stress activation of corneal epithelial cells cultured
`in hyperosmolar media.
`2
`
`After a patient starts on an artificial tear, she needs
`frequent follow-up to determine whether the drop is
`relieving symptoms. “They may need to use the drop for a
`month or two before they can determine whether it will
`work for them,” says Dr. Sheppard.
`
`Jay Pepose, MD, PhD, medical director of Pepose Vision
`Institute and president of the Lifelong Vision Institute, St.
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 10 of 12
`
`Louis, relies on a combination of symptoms and tear
`osmolarity to assess the efficacy of treatment. “I test
`patients’ tear osmolarity before I initiate treatment, and
`then I ask them not to use any tears or put anything in their
`eye for at least 30 minutes, but preferably for at least an
`hour, before they come in for follow-up, and then I re-test
`their tear osmolarity after they have been on a product for
`a few weeks,” he says. “Changes in tear osmolarity, along
`with vital staining and tear breakup time and reduction in
`symptoms, help me to decide whether patients are using
`the appropriate product or if we may need to switch tears,
`supplement treatment with cyclosporine, consider
`doxycycline or punctal plugs or add omega-3s.”
`
`Dr. Latkany notes that artificial tears are helpful as
`adjunctive agents, but that they are not the answer for dry-
`eye patients. “None of these can come close to the
`complexity of our natural tears,” he says. “I am not in love
`with any of them, but we are improving the options. I think
`the marketing campaigns from the pharmaceutical
`companies make these products appear very attractive and
`very complex and to appear to be the answer to all dry-eye
`patients, but that is far from the truth, and we have a long
`way to go.” REVIEW
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
`
`Page 11 of 12
`
`1. Sarkar J, Chaudhary, Namavari A, et al. Corneal neurotoxicity due to topical
`
`benzalkonium chloride. Invest Ophthalmol Vis Sci 2012;53(4):1792-1802.
`
`2. Corrales RM, Luo L, Chang EY, Pflugfelder SC. Effects of osmoprotectants on
`
`hyperosmolar stress in cultured human corneal epithelial cells. Cornea 2008;27:574-579.
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`
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`
`Page 12 of 12
`
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`Copyright © 2017 Jobson Medical Information LLC unless otherwise noted.
`All rights reserved. Reproduction in whole or in part without permission is prohibited.
`
`https://www.reviewofophthalmology.com/article/otc-drops-telling-the-tears-apart
`
`
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