Table 12.4 Poll of artiÞcial tear preference

tears that can be used more frequently (as they lack preservative).

¥Another trade-off is the viscosity of the tear that makes it last longer but may lead to transient blurred vision.

¥The patient must be prepared to mix and match the frequency and type of tear to match their symptoms and environment.

¥An additional point is that nighttime use of gels and ointments may prove very helpful so that the patient does not arise in the morning with a severely diminished tear Þlm and already compromised ocular surface.

¥Artificial tears containing preservatives

should not be used more than four times a day; preserved tear products contain substances that can lead to ocular surface epithelial toxicity.

¥Even if we use preservative-free artiÞcial tears in our dry eye patients, patients may still be receiving other eye drops (such as treatment for glaucoma or infection) that may contain a preservative. Thus, we have to consider the entire cumulative effect of preservatives on the eye.

¥Gels may not be as effective as ointments, but the gel produces less blurring and dissipates faster. However, some people do not tolerate gels, perhaps due to the preservatives. We often suggest an initial trial of Refresh PM (ointment), GenTeal gel (may have preservative), or Lacrilube (ointment).

¥It is important not to overuse the gels or ointments, as they may leave a residue on the lashes. A small amount (such as 1/8 inch or less) should be used.

12.6Additional Types of Therapy

Lacriserts are solid pellets of hydroxymethylcellulose that are placed under the lower lid. The pellet is dissolved slowly in patients who retain sufÞcient tear ßow to dissolve the pellet. We have found that some patients with mild dryness can obtain beneÞt. The patient must have good dexterity to insert the pellets and avoid corneal abrasion. Also, a decrease in tear ßow, even transiently as weather conditions or concurrent medications change, these pellets may not be adequately dissolved and the patient experiences irritation and blurring.

Mild topical steroids (such as Lotemax) have also been used to alleviate symptoms of dry eye disease. They are remarkably effective at rapidly reducing or eliminating the inßammatory component and breaking the vicious cycle.

Even mild topical steroids, however, entail the risks of secondary glaucoma, cataract induction, increased susceptibility to infection, and dependence. Some patients really do become physiologically dependent upon the soothing effect of topical eye steroids (not unlike dependence upon lip balm that temporarily soothes chapped lips), and it may be difÞcult to wean-off after prolonged use.

For all these reasons, most ophthalmologists use steroids only for limited periods of time to help patients through severe symptomatic episodes. Topical steroids can also be used temporarily for more rapid relief in conjunction with the institution of topical Cyclosporine-A until the latterÕs pharmacologic effect develops sufÞciently.

Another remarkably effective topical therapy is the use of autologous serum tears. Patients unresponsive to other intensive treatment often show remarkable subjective and objective improvement with the use of teardrops made from their own serum, which most likely contains many essential and restorative components.

Our own positive experience with autologous serum tears [19] has been corroborated by numerous reports in the literature [20Ð23]. Elsewhere in this book, a chapter by Saito and Tsubota of Japan

relate their experience and method for preparing autologous serum tears.

For the motivated patient in distress, the logistics involved in preparing and using serum tears are certainly worth the effort. The use of tears made from umbilical cord blood, or simply the

use of a dilution of commercially available gammaglobulin (IV-Ig), has also been reported [23].

In the United States, enlisting a co-operative laboratory can be complicated by concerns over liability due to potential contamination of these preparations.