Artificial Tears: Choose What Feels Good

Part 1: Let’s talk about artificial tears 

Consumers are spoiled for choice these days.  Artificial tears occupy most of the shelf space in the Eye Care section of your typical bricks-and-mortar pharmacy. 

One concept behind the use of artificial tears is that chronically dry eyes are inflamed eyes.  You wet your dry eyes, your eyes are no longer dry, the inflammation improves, and over time you feel better.  Therefore, dry eye patients should search for the product that does the best job of keeping their eyes lubricated, and this will lead to the greatest reduction in inflammation and thus in symptoms.  You might have to put up with an eye drop that stings or causes protracted blurred vision, but this unpleasantness is just part of your investment in healing your ocular surface. 

For many patients, this concept is wrong. 

Instead, you should go with what feels good. 

We’ll explore this idea by considering two different patients:  Patient Temporary and Patient Chronic. 

Part 2: A tale of two patients 

Patient T spent two nights in a hotel with a squishy pillow and AC blasting directly at the head of the bed. Awakening the second morning, Patient T had scratchy eyes, right eye worse than left, which did not improve after a shower.  His right eye was blurry.  Most likely Patient T has corneal and conjunctival dryness induced by the blasting AC and squishy pillow contact.  On examination the corneas would show staining, right worse than left, with central staining in the right eye to explain the blurred vision.   

Patient T should run to the drugstore and buy a preservative free artificial tear labelled “for severe dry eye” and use it every 1 – 2 hours until he feels completely better.  The purpose of the artificial tear is to create an environmental barrier between the world and the ocular surface, while Patient T’s fundamentally healthy corneal epithelium plumps up and proliferates to re-create a smooth corneal surface.  Patient T has to suck it up and deal with the blurred vision induced by the highly viscous artificial tear.  He needs a thick barrier and long retention time.  Stinging on instillation is not surprising, no matter what product he uses, because he has a lot of naked corneal nerve terminals waving in the breeze.  Deal with it for a few hours, already. 

Patient C is you.  You have chronic dry eye disease. This could be for one specific reason like aqueous deficiency due to Sjogren syndrome, a constellation of definable reasons, or no clear reason.  You have corneal and conjunctival staining on examination, although the amount of stain may be less than the amount of pain.  The pain and the stain don’t seem to correlate:  you can have a low-stain exam on a day when you have a lot of pain.   

You have this mental construct of your problem that says, ‘Get rid of the stain and this will reduce the pain.’  This leads you to hyper-analyze your artificial tears, looking for that perfect product, or combination of products, which will reduce your stain, reduce your inflammation, and reduce your pain.  You haven’t found it yet and you’ve been trying for years. 

In desperation, Patient C-type dry eye patients will use artificial tears that are unpleasant because they believe that those products have a better chance of resolving corneal stain.  Maybe these products are very viscous and cause protracted blurred vision, or maybe they are the Meibomian oil mimics which sting.  Whatever. 

I’m here to tell you...quit all that.  The dryness symptoms are the problem.  Treat the problem. 

Part 3: The Heretical Liberation Philosophy of Artificial Tears 

Use artificial tears to reduce dryness symptoms, however you experience those symptoms (dry, gritty, stinging, burning, foreign body sensation, tired, etc.).  You always know your own symptom level, because by definition a symptom is something a patient feels, not something a doctor sees. 

Pick whatever product(s) give you the best symptom relief with a reasonable trade-off for vision blurring.  This may not be the same product all day long.   

The key is that you aren’t going to make yourself feel worse while trying to make your stain better anymore.  After all, making your stain better is not guaranteed to make you feel better.  So screw the stain. 

I call this the Heretical Liberation Philosophy of Artificial Tears.  (Yes, the acronym is terrible.)  You’re the liberated person.  I’m the heretic. 

Now you, Patient C, can do simple experiments on your own to determine which preservative free artificial tears usually make your symptoms better even if only slightly or briefly, and which products either don’t help at all, or are so unpleasant (stinging on instillation, impractical blurred vision) that you hate using them.  Throw those out.  Do not pay any attention at all to alleged benefits such as replacing specific tear film components or containing tasty nutritional ingredients or antioxidants. 

Part 4: Keep Up Don’t Catch Up 

Your mission is to find one or two artificial tears that you don’t dread, and then use them consistently throughout the day.  Use your smart phone for something smart and have it alert you every 1 to 2 hours that it’s tear time.   

This means you must get yourself out of your chair and do your drops even if you have no symptoms at that moment, or mild symptoms that are not intruding on your consciousness / causing emotional distress because you are doing something interesting like winning a magic sword. 

Let me say it again:  The core tenet of the HLPAT is that you are using a preservative free artificial tear that doesn’t hurt, or mess with your vision for an hour, so you can use it consistently and frequently.  Don’t kid yourself that lack of symptoms in the moment means that your tear film is fine.  If you wait until your eyes are bothering you enough to make you want to use your artificial tears, you’ve waited too long.