Article Date: 10/1/2004

Artificial Tears & Your Dry Eye Patients
Patients look to you for your recommendation. Will you educate them or turn them away?
BY NEIL D. DONNENFELD, M.B.A., Woburn, Mass.


At a time when the number of dry eye sufferers continues to climb, consumer data indicates dissatisfaction and confusion over artificial tears, the most common treatment for dry eye. During the 52 weeks ending July 11, 2004, 18 of the top 25 artificial tears showed decreased sales over the previous year (See "Tears: Behind the Numbers" on pg. 68). This dissatisfaction negatively impacts tear manufacturers, optometric practices and most of all, millions of patients. How do we transform this chaos into a win-win-win situation?

Navigating the OTC maze

First, let's diagnose the problem. Patients who suffer from dry eye typically make one of two choices:

1. They will schedule an appointment with their optometrist

2. They will visit their local retailer or discounter to purchase artificial tears.

The second option can challenge the most discriminating patient (the typical drug store stocks more than 50 dry eye products). Compounding the problem is the issue of labeling. Each of the products communicate essentially the same message because the FDA mandates what companies can and can't print on the label.

In this scenario, the self-diagnosing, self-medicating patient must evaluate ingredients and decide whether to buy a drop that's preservative-free, becomes preservative free on eye contact, has a mild preservative or doesn't mention a preservative at all.

When the patient visits

Sometimes patients who visit their optometrists are no better served than if they went directly to the store because their optometrist doesn't educate them on which tear, or type of tear, to buy. Remember that the majority of patients will act on their optometrist's recommendation. Frequently, the recommendation is predicated on whatever tear sample happens to be available.

In other cases, optometrists employ the "grab bag," or trial-and-error approach, which involves handing out a few different samples. These doctors tell patients to try them all and they let the patients choose the artificial tear they like best. In either case, samples "speak for themselves" in lieu of specific medical advice.

Industry trade journal articles confirm the absence of patient guidance. "Historically, the selection of an artificial tear has been directed by trial and error between the physician and patient," notes a recent article. A popular consumer eyecare Web site advocates trial-and-error as the best approach to over-the-counter (OTC) artificial tears. The site advises patients to switch if their current product stops working.

Sampling dangers

The "grab bag" approach devalues tears as therapeutic agents. In essence, the optometrist says, "I don't know the difference between these products, so here, try these samples and see which one works for you." This sends a message to patients that the optometrist doesn't recognize the differences among tears, or that these differences aren't worthy of the optometrist's attention. At a minimum, doctors should recommend that patients not use products that contain preservatives known to exacerbate dry eye.

If all artificial tears contained the same combination of ingredients, then allowing patients to sample and identify a favorite brand wouldn't be an issue. (See "The Error in Trial and Error" on page 70.) But tears are compounded differently, are preserved differently, and, therefore, have different degrees of efficacy and toxicity. Some tears remedy dry eye while others can exacerbate the condition. Patients require the proper guidance to select the appropriate tear.


Tears: Behind the Numbers


Sales data confirms patient dissatisfaction with artificial tears. For the 52 weeks ending July 11, 2004, 18 of the top 25 artificial tear products sold in food, drug and discount stores (excluding Wal-Mart) lost sales over the previous year. (These 25 tears represent 67% of the market.)

Six of the seven products showing growth fall into one of two categories:

1. Private-label brands

2. New products.

Private labels garner sales because they're priced lower than manufacturer-branded tears. If patients don't discern a quality difference between tears, they'll naturally select the most economical alternative.

But why are new products growing while established products give way? I'd submit that frustrated patients gravitate toward the most recent entries in the hope that a new product will be better than what they've been using. If the new product isn't appropriate for the their needs, however, the patient will most likely move on to the next "latest and greatest" brand.

From patient to consumer

Without professional medical guidance, the patient will usually act as a consumer. The same can be said of the patient who doesn't realize a dramatically positive or negative response to one sample. But such a response is not unusual. That's because most samples contains only a few doses, while research has shown that it may take days or weeks to realize the full benefits (or adverse affects) of a particular tear.

As a consumer, the patient will choose the store's private label -- the low-price brand -- or a brand that advertises through consumer media. Because most of these products contain preservatives, are hypertonic or lack the proper electrolyte balance, the patient is likely to wind up with a product that exacerbates or fails to reduce symptoms. The results are:

As a manufacturer, I often hear optometrists tell us that they won't recommend our tear unless the manufacturer provides them with samples. Sample availability is a poor reason for a doctor to recommend a specific tear, especially when the doctor can use a prescription or coupon pad provided by the manufacturer where no sample is available.

Manufacturers on samples

Many optometrists inquire about the supply or scarcity of samples. Here is the manufacturer's explanation of how the relationship between optometrists and sampling ought to work: The manufacturer relies on optometrists to dispense samples of -- and recommend -- a tear to a specific patient based on the scientific merits of the product. The optometrist's recommendation strongly influences the patient who purchases the product. Because it's the appropriate tear, it effectively treats the patient's dry eye. As a result, compliance increases, the optometrist's reputation is enhanced and tear sales increase. Increased sales help us to invest in research and future sampling efforts, which are two of the largest expenses in a drug company's budget.

Optometrists can make great strides in their treatment of patients who have dry eye simply by recommending artificial tears that they know won't hurt patients. At a minimum, patients should use tears that are either nonpreserved, transiently preserved or preserved with a mild agent that doesn't irritate sensitive eyes. Stable preservatives, particularly benzalkonium chloride, exacerbate symptoms in sensitive eyes.

Make an informed decision

Optometrists don't have to blindly choose a preferred artificial tear. With the wealth of information now published each year, doctors can investigate ingredients and provide recommendations based on the fundamental differences between tears. Here are some areas to investigate:

If a doctor is confused about the efficacy of different tear formulations, he should understand that patients who have dry eyes are unusually sensitive to chemicals on the ocular surface, as well as to stable preservatives.

In the end, it's education

Symptoms of dry eye disease are among the most common presenting complaints in optometry. The most effective treatment regimens exist when the manufacturer, doctor and patient work together. Dry eye patients and manufacturers depend on the optometrist to present education and information to patients. Providing tear samples may help patients in the short term, but education lasts a lifetime.

References available on request.


The Error in Trial and Error

The trial-and-error approach to artificial tear sampling is almost always counterproductive-- especially in light of what we know about artificial tear ingredients. Benzalkonium chloride (BAK), found in six of the top 30 tear products sold in the United States, is known to exacerbate dry eye. Studies have shown that BAK-preserved artificial tears may produce damage to the corneal epithelium. Published reports document the move to reduce BAK, or eliminate it if possible, in topical medications.

When a sample containing BAK is part of the trial-and-error process or is the only sample given, it's likely that patients will continue to be frustrated by artificial tears. Recommending any inferior tear product perpetuates dissatisfaction with all tear products, isn't helpful to the patient and erodes segment sales.


Mr. Donnenfeld is vice president of sales and marketing for Advanced Vision Research, makers of TheraTears. He received his M.B.A. from The Wharton School and is a former brand manager at Procter & Gamble.



Optometric Management, Issue: October 2004