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#350 Not a Dry Eye in the House – Looking into Artificial Tears

How effective are artificial tears for dry eye syndrome?

While most products improve symptom scores, comparisons to placebo/no treatment are rare. Differences in patient outcomes between artificial tear products (including preservative versus preservative free) are rare, inconsistent, and likely unreliable.  Product selection can be guided by costs and personal preference.

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  • Two systematic reviews with 43-64 randomized controlled trials (RCTs) reviewed individually for patient-oriented outcomes. Most excluded post-surgical and contact lens wearers.1,2
    • Artificial tears versus “placebo”/no-treatment:
      • RCT (304 patients): Symptoms like dryness/soreness (scale 0-15, higher worse, baseline ~8).3
        • At 28 days: 5.7 sodium hyaluronate versus 6.1 saline drops, statistically but not clinically different.
      • RCT (27 computer-users, many without dry eyes) compared three different artificial tears to ‘no product’.4
        • All interventions, including ‘no product,’ reduced patient symptoms, without difference between groups.
    • Artificial tears versus each other:
      • Validated patient symptom scale (0-100, higher worse, minimal clinically important difference=4.5): 18 RCTs; 27-445 patients with moderate-severe dry eyes. Of 36 different comparisons,1,2 three were statistically different:
        • Industry funded RCT (40 patients): At 90 days, cross-linked hyaluronic acid/coenzyme Q10 combination improved 16 points versus 8 points for hyaluronic acid alone.5
        • RCT (110 patients): At 30 days, final scores differed by 3 points (biased by differing baselines).6
        • RCT (120 patients): 12-week scores for sterile isotonic seawater washes were 4.5 points better than carmellose drops.7
      • Other patient-oriented symptom scores, 6 RCTs with ≥100 patients.3,8-12 One statistically different:
        • 135 patients, hypotonic 0.4% hyaluronic acid versus 0.3% hydroxypropylmethylcellulose. Example: Proportion attaining ‘mild or resolved’ burning or foreign body sensation at 60 days: 19%-36% more patients on hyaluronic acid.10
    • Preservative versus preservative-free artificial tears:
      • Systematic review (2 RCTs, 271 patients): No difference.13
  • Limitations: High risk of funding bias,5,10 chance findings (many RCTs, differences rare), and some biased analyses.6,10

  • Over-the-counter product costs vary (<$10 to >$50) with preservative-free typically being more expensive.14
  • Guideline recommends preservative-free products if intolerant to preservative, soft/hybrid contact lens wearers, use of other eye topicals with preservative, or if drops required ≥4 times/day.15
  • Non-topical interventions include warm compresses and lid hygiene.16

H WILLIAM October 17, 2023

Good to know

Michael Hughson October 17, 2023

Once again the OTC industry selling placebo.

Nancy Craig October 19, 2023

Is there a real problem with NOT treating dry eye? Regardless of symptom relief (or not) with whatever product, what are the sequelae of untreated dry eyes?

Mitchell Schipper October 19, 2023

Helpful study

William Dobson October 30, 2023

I am surprised by these results. My optometrist and ophthalmologist both suggested the drops.

Peter Barnsdale October 31, 2023

Reasonable to present to patients and leave it to them.

Chinonye Nwankwo November 28, 2023

Perhaps personal preference is influenced by the treatment outcome for the product used- with or with preservatives.

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  • Betsy Thomas BSc. Pharm
  • G. Michael Allan MD CCFP
  • Jessica Kirkwood MD CCFP (AM)

1. Pucker AD, Ng SM, Nichols JJ. Cochrane Database Syst Rev. 2016; 2(2):CD009729.

2. Semp DA, Beeson D, Sheppard AL, et al. Clin Optom (Auckl). 2023; 15:9-27.

3. Baeyens V, Bron A, Baudouin C; et al. J Fr Ophtalmol. 2012; 35(6):412-419.

4. Calvão-Santos G, Borges C, Nunes S, et al. Eur J Ophthalmol. 2011; 21(5):538-44.

5. Postorino EI, Rania L, Aragona E, et al. Eur J Ophthalmol. 2018; 28(1):25-31.

6. Dumbleton K, Woods C, Fonn D. Eye Contact Lens. 2009 May; 35(3):149-55.

7. Diaz-Llopis M, Pinazo-Duran MD, Diaz-Guiñon L, et al. Clin Ophthalmol. 2019; 13:483-490.

8. Bron AJ, Daubas P, Siou-Mermet R, et al. Eye (Lond). 1998; 12(Pt 5):839-47.

9. Cohen S, Martin A, Sall K. Clin Ophthalmol. 2014; 8:157-164.

10. Iester M, Orsoni GJ, Gamba G, et al. Eye (Lond). 2000 Dec; 14(Pt 6):892-8.

11. Jerkins G, Greiner JV, Tong L, et al. Clin Ophthalmol. 2020; 14:1665-1673.

12. Labetoulle M, Schmickler S, Galarreta D, et al. Clin Ophthalmol. 2018 Dec 5; 12:2499-2508.

13. Ribeiro MVMR, Barbosa FT, Ribeiro LEF, et al. Arq Bras Oftalmol. 2019; 82(5):436-445.

14. 2023. Available at: Accessed September 5, 2023.

15. NHS Guideline for Treatment of Dry Eyes in Primary Care. Available at:,type%20or%20solution%20may%20help.&text=Increase%20relative%20humidity%20and%20avoid%20prolonged%20periods%20in%20air%2Dconditioned%20environments.&text=Lower%20computer%20screens%20to%20below,with%20computer%20use%20and%20reading. Accessed on September 5, 2023.

16. Prokopich CL, Bitton E, Caffery B. CJO. 2014; 76,Suppl 1.

Authors do not have any conflicts of interest to declare.