The Dry Eye Zone

Rebecca's Blog


Red Alert: What you should know about those eyedrops

Red Alert.png

Red eyes.

It happens. For many people, it's just an occasional thing.

But for others, it happens regularly. Maybe even daily. And it's not just annoying. It's embarrassing. People ask, or comment, or joke, or snicker. Or they say nothing, but you know they noticed. You start to worry more about the impression people are getting and the assumptions they might be making. And when you are hyper-conscious of the appearance of your eyes, you find yourself less comfortable even making eye contact. It's a seriously inhibiting problem to have when it's persistent or chronic - at school, at work, even (or perhaps especially) socializing.

So you reach for the eyedrops.

Pretty soon, your eyes look (maybe even feel) better. 

That's how it works, right?

Yes! Until it doesn't!

If you think that clearing up red eyes really is that simple, you are approaching the cardinal sin of believing in free lunch. Life in fantasyland is peachy, especially when we passively submit to having our would-be harmless illusions discreetly propped up by omnipresent marketing.

If you have any inclination whatsoever to question the tooth fairy, take a few short minutes to cover some simple facts with me about eyedrops that contain redness relievers.

MOST redness relievers pose 2 out of 2 hazards:

(1) Rebound redness, which is exactly what it sounds like (if you want to know more, prowl through the 329,000 Google hits) and/or

(2) A toxic preservative called benzalkonium chloride (or BAK for short). When I say toxic, I mean specifically toxic to the surfaces of the eye (cornea and conjunctiva), ranking right up there with thimerosal according to this study. The specialists' dry eye bible on drugs that cause dry eye (TFOS DEWS II, Iatrogenic Report) lists seven different ways in which the preservative BAK harms your eyes, from cell damage to nerve damage to an inflammatory vicious cycle. Lengthy use and frequent exposure to this preservative is Not A Good Thing.

Which drops fall in this double-trouble category? Oh, almost all of them. We're talking Visine, ClearEyes, Rohto - all drops under these names that mention redness reliever on their labels contain active ingredients associated with the rebound redness effect AND they nearly all have the infamous BAK preservative. In other words, if you use them regularly, they will get you coming and going. They will become less and less effective and can make the redness worse in the short term; but they can also wreak havoc with your eye's self-lubrication system and surface health for the long term, which frankly is a much more serious worry.

So what are the better choices? Hmm, let's see:

THE REST of the redness relievers (yes, Lumify too) pose 1 out of 2 hazards:

Clear Eyes Pure Relief Multi Symptom is preservative-free, which is great - that means it does not pose the long term risks of BAK. However, its redness reliever active ingredient is associated with the redness rebound effect. So, it may get you in the short term if you overuse it. On the other hand, watch out - Clear Eyes brand sports 10 different eyedrops, 6 of which have the BAD (oops, I mean BAK) preservative. So be prepared to squint at the labels to make sure you get the right thing, if this is the one you're aiming for!

Then there's the new kid on the block:

Lumify, the new B&L drop being touted everywhere as the "safe" redness reliever. How does it measure up? Lumify is believed to have a much lower risk of rebound redness. Lumify is very fast acting and let me tell you, it is simply the perfect instant-gratification drug. But... it does have the toxic preservative BAK. In other words, Lumify is a short term winner with a long term toxic effect (that is, for those who overuse it - which is common).

Pardon me one moment while I climb up on my soapbox and re-hash a little bit of history....

There is a painful irony in the roots of Lumify. The active ingredient (brimonidine) has been used for a long time in a much higher dose as a glaucoma medication called Alphagan. Glaucoma medications, for background, are notorious for causing dry eye in the elderly because (a) they are used daily, maybe multiple times daily and (b) they have traditionally all been preserved with benzalkonium chloride while being used every day, sometimes multiple times a day - and it is this daily exposure to benzalkonium chloride that is so damaging. So around 15-20 years ago the drug makers started bowing to necessity and rolling out preservative free glaucoma drops and glaucoma drops with milder preservatives. It's been an excruciatingly slow process for this switchover to happen - like watching grass grow in July. The makers of Alphagan (Allergan) jumped on this bandwagon relatively early on, with Alphagan-P. Now along comes Lumify (from Bausch & Lomb), which is low-dose brimonidine, that is, the same drug, but... with the BAK added back in, and sold over-the-counter, so no eye doctor is monitoring what's going on and switching the patient to something safer as needed. B&L, that's a disappointing move in the wrong direction. This is 2018, and I think we all know what preservatives are now. You had an opportunity to be a leader - to combine short term benefits with improved long-term risk profiles, and as far as I'm concerned, you blew it.

Climbing back down....

So pick your poison.

If you are a frequent consumer of drops to relieve redness, your three options are: short term side effects, long term side effects, or both. 

Is there another path? A realistic, not idealistic, path? Maybe.

  1. If you can't go cold turkey, at least cut down on redness relievers. Never more than once a day - but try to wean down to a couple times a week at the very most. Ideally, these drops should be for special occasions only.

  2. If your eyes are irritated (as opposed to red), use lubricant drops only, preservative free only. If it's in a bottle*, don't buy it. Buy stuff in vials with twist-off tops - they are preservative free.

  3. Cold compresses and cold eyedrops are your friends!

  4. If you are abusing contact lenses, the sooner you face reality and quit, the better. If you cannot face life without contacts, find a doctor specializing in scleral lenses. Google that too.

  5. Getting a decent night's sleep is helpful, if you aren't already. Your natural tear system can't do its job well without enough shut-eye.

  6. Most of all, please, please get to a corneal specialist ophthalmologist to get a full assessment. These are the doctors with the most training in all of the things that may be contributing to your eye redness. It's always a good idea to get to the source of the problem if you can. Chronically self-treating with toxic stuff is not in your long-term best interest. You can spend a little money to be told the truth now, or you can endure all the things the cornea specialist will be saying to you five or ten years hence about how preventable this was.

Any optometrists visiting this page?

I have watched in dismay as Lumify gets lauded to the skies as the new OTC wonder-drug: a "safe" redness reliever! The social media frenzy is in full swing. 

The problem is, Lumify is not safe. It's just less unsafe. Call it safe, or even equivocate enough to make it sound safe, and people will use more of it then ever before - and will proselytize everyone within reach, because the instant gratification factor is compelling. Meantime, the label is completely useless at explaining risks - in fact, the FDA-mandated language shares a lot of the same language as preservative free lubricant drops, which makes no sense whatsoever. But it doesn't matter, because the truth is, people don't read labels. They assume that if it's sold without a prescription, it's safe.

So, a few little points to consider:

  1. Absence of the lesser of two vices does not equal a virtue.

  2. BAK toxicity is quite well established in the medical literature.

  3. It's up to you to educate patients.

Optometrists, you are uniquely positioned to offer an effective counter narrative to the marketing hype. Educate, educate, educate. Even if your patients don't bring it up, please, bring it up yourself as a matter of safety and prevention. The ones most at risk are the ones that never go to the eye doctor till they've self-medicated forever for their "minor" complaint. Every patient you educate about this will educate other people they know, reaching many of the ones who are not getting proper diagnosis and treatment. After all, people love to brag about their eye doctor and share what they learned that no one else seems to know yet. So tell them!


p.s. Clocking off at 12:27 am to go care for my red eyes... saline rinses, cold packs and as much sleep as I can squeeze in. Oh, and making a note to call for that overdue appointment with my dry-eye-specialty optometrist.

*Note about bottles: There are a few eyedrops sold in special preservative-free bottles - but those are patented bottle designs that do not look or feel like regular eyedrop bottles. Examples of those include Clear Eyes Pure Relief (that's the preservative free redness reliever mentioned above) and Oasis Tears Preservative Free Multi-Dose (and artificial tear). But if you want to stay safe, either look for an explicit "Preservative free" on the label, or stick with single vials for everything.