Eyeworld

68 | EYEWORLD | WINTER 2024 C ORNEA by Ellen Stodola Editorial Co-Director About the physicians Anat Galor, MD, MSPH Professor of Ophthalmology Bascom Palmer Eye Institute Miami, Florida Stephen Pflugfelder, MD Director of the Ocular Surface Center Cullen Eye Institute Baylor College of Medicine Houston, Texas John Sheppard, MD Senior Founding Partner Virginia Eye Consultants and EyeCare Partners Practice Professor of Ophthalmology Eastern Virginia Medical School Norfolk, Virginia M any patients use drops to help with a variety of ophthalmic issues, however, one thing to consider is the formulation of these products, specifically if they have preser- vatives. Three ophthalmologists discussed the precautions with preservatives and shared the importance of monitoring for toxicity and po- tentially finding alternative treatment options. Anat Galor, MD, MSPH, said finding a preservative-free product is not as easy as you would think. "We're always jealous because in Europe, they have a ton of preservative-free products," she said. When talking about chronic medications like for glaucoma, the non-pre- served medications are much more expensive. The best option would be to never use preservatives, but it's not always feasible, so Dr. Galor tries to identify the patients who have toxicity from preservatives, mostly based on epithelial staining patterns, and tries to switch those that show adverse effects. Dr. Galor offered several key principles in these scenarios: 1) Don't have patients on medications they don't need; carefully consid- er if they need chronic medications; 2) talk to patients about different types of medications, what they're buying over the counter, etc., and make sure they're making good decisions; 3) monitor for toxicity in anyone who uses chronic eye drops with preservatives; in the office, stain with vital dyes, and if you see it, that's a patient population where you can consider other op- tions. It doesn't have to be non-preserved drops; it could be options like SLT. Stephen Pflugfelder, MD, also shared the concern of corneal and conjunctival epithelial toxicity with preservatives. This is most relevant to drops preserved with benzalkonium chloride (BAK), he said, which can cause corneal barrier disruption leading to an irregular and dry corneal surface that can reduce visual function and cause irritation. It can also cause death of conjunctival goblet cells, thus reducing secre- tion of tear-stabilizing mucin from these cells. Dr. Pflugfelder said that if possible, reducing the frequency of instillation or switching to a preservative-free formulation should be consid- ered to help with the effects of these products. The risk of toxicity is related to the frequency of use and the BAK concentration. Usually, most patients can tolerate one drop with BAK preser- vative per day. Dr. Pflugfelder said there aren't many circumstances where you would need to use a product with preservatives. Theoretically, BAK-preserved antibiotic drops may be more effective for treatment of bacterial keratitis because the preservative can provide added bactericidal activity. However, severe corneal infections are often treated with compounded preservative-free fortified antibiotics. John Sheppard, MD, noted two sets of concerns to consider with preservatives—short term and long term. In the short term, normal people will be fine with preservatives, he said. One example is antibiotics. In the past, companies have adver- tised a synergistic effect between the preserva- tive and antibiotic. In short-term use, they're fine for a normal surface. "If the patient has ocular surface disease, even the short-term use of a preservative can exacerbate ocular surface disease," he said, adding that moxifloxacin is a preservative-free option. In a situation where you're concerned about toxicity, this could be a Preservatives in ophthalmic medications and alternative strategies Meibomian gland dropout in patient with long-standing glaucoma medication use Source: Anat Galor, MD, MSPH

• Blank Page
• Blank Page (1)