ARTIFICIAL

TEARS

Muhsin Anis – 30101507507

Supervisor : dr. dr. Nika Bellarinatasari, Sp.M
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Anatomy and
Physiology
Tears
￮ Tears form a thin layer approximately 7–10 μm
thick that covers the corneal and conjunctival
epithelium. The functions of this ultrathin layer
are:
i. to make the cornea a smooth optical surface by
abolishing minute surface epithelial irregularities;
ii. to wet and protect the delicate surface of the corneal
and conjunctival epithelium;
iii. to inhibit the growth of microorganisms by mechanical
flushing and antimicrobial action;
iv. to provide the cornea with necessary nutrient
substances.
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 Superficial

LAYERS
OF TEAR
FILM

Middle Deep

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Superficial
￮ The superficial lipid layer is a
monomolecular film derived
from Meibomian glands.
It is thought to retard evaporation
and form a watertight seal when
the lids are closed.

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Middle
￮ The middle aqueous layer is
elaborated by the major and
minor lacrimal glands and
contains water-soluble
substances (salts and
proteins).

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Deep
￮ The deep mucinous layer is composed
of glycoprotein and overlies the corneal
and conjunctival epithelial cells.
The epithelial cell membranes are
composed mainly of lipoproteins and are
therefore relatively hydrophobic.
Mucin is partly adsorbed onto the corneal
epithelial cell membranes and is anchored
by the microvilli of the surface epithelial
cells. This provides a new hydrophilic
surface for the aqueous tears to spread
over, which is wetted by a lowering of
surface tension.

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 Proteins Albumin

Electrolytes
and other
60% products
Normally • Glucose 5 mg/dL
isotonic • Urea 0.04 mg/dL
21 – 26% 
(295 – 309
mosm/L)
Lysozyme COMPOSITION IgA, IgG, IgE
(7 ± 2 μL each eye)

Immunoglo-
Enzymes bulins
Normal pH:
40% 7.35
(5.20 – 8.35)

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2
Artificial
Tears
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 ￮ Artificial tears, particularly
“ ￮ preservative-free tears in
more advanced cases, are
the mainstay of
symptomatic
￮ treatment.

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 ￮ The goals of artificial tear

“ treatment are

Decrease Dryness (acts as Increase tear retention,

lubricant, reduce friction) preserve osmolarity

Decrease Inflammation Soften and moisturize

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Based on the FDA Monograph there are several
types of Artificial Tears used, depending on the
cause of the “Dry Eye.” Of those types are:
1. Ophthalmic Astringent
2. Ophthalmic Demulcent
3. Ophthalmic Emollient
4. Eyewashes

Other classes from the FDA Monograph however should be used

with caution by certain literatures are:
- Hypertonicity agents  when there is corneal edema
- Ophthalmic Vasoconstrictors  careful use

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Ophthalmic
Astringent
A locally acting pharmacologic agent
which, by precipitating protein, helps
to clear mucous from the surface of
the eye when the cause is due to
tenacious mucous
1. Mucolytic agents such as
Acetylcysteine 10% or 20%
2. Zinc Sulfate 0.25%

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Ophthalmic
Demulcent
￮ An agent, usually a water
soluble polymer, which is
applied topically to the eye to
protect and lubricate mucous
membranes

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Polyethylene glycol (PEG) is a demulcent that
forms a protective layer over a mucous membrane
to relieve inflammation or irritation and to preserve
the ocular surface microenvironment. Demulcents
are high molecular weight polymers that mimic
mucins and act to lubricate, protect and provide
viscosity to eye drops.

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Propylene glycol also forms a protective layer
over mucous membranes to relieve inflammation
and/or irritation. It also increases the viscosity of
the eye drop. In addition to its demulcent
properties, propylene glycol is a humectant
because it holds up to three times its own weight
in water.

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Glycerin is a demulcent and lubricant as well as a
humectant. Glycerin has the added properties of
promoting epithelial cell growth and blunting the
damaging effects of high osmolarity on the ocular
surface.

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Povidone is a lipid that integrates with the
existing oil layer of the tear film, thickening it to
reduce evaporation. Dextran is a low molecular
weight hydrophilic polymer that increases the
mechanical strength of the tear film. Its low
viscosity means that it is not useful in an artificial
tear without a thickening agent.

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Dextran is a low molecular weight hydrophilic
polymer that increases the mechanical strength of
the tear film. Its low viscosity means that it is not
useful in an artificial tear without a thickening
agent.

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There are a number of compounds that are cellulose derivatives
that are approved for use in artificial tears.
Carboxymethylcellulose (CMC) is the most commonly used
polymeric viscosity agent in the United States. CMC binds to and
is retained by corneal epithelial cells. It increases the viscosity
and clearance times of an eye drop and is also widely used in
foods, pharmaceuticals and non-food products such as tooth
paste and detergents.

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Hydroxymethylcellulose (HMC), hydroxypropylcellulose
(HPC), and hydroxypropylmethylcellulose (HPMC, aka.
hypromellose) are all hydrophilic polymers that coat and protect
the eye. They are hydrogels that crosslink upon contact with the
ocular surface to increase tear clearance times. They must be mixed
with other compounds because they are too viscous to instill alone
onto the ocular surface. HMC is restores the protective effect of the
mucous layer of the tears

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Ophthalmic
Emollients
￮ Emollients are oily or fat based agents which are
used to soften and protect tissues to prevent
cracking or drying. Emollients are non-
moisturizing, but they do function to seal in
existing moisture.
Mineral oils thicken or replace the lipid layer of the
tear film to increase tear stability and tear break up
time.
White petrolatum and the lanolin preparations are
lubricants.
The majority of products containing mineral oil and
white petrolatum contain only those two components
in varying proportions.

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Eyewashes
￮ Aqueous deficiency can be treated with
various preparations.
The simplest are physiologic (0.9%) or
hypo-osmotic (0.45%) solutions of
sodium chloride, which can be used as
frequently as every half-hour, but in most
cases are needed only three or four times
a day.

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Preservatives
￮ Can be a potent source of toxicity, especially after
punctal occlusion.
￮ Numerous non-preserved drops are now available,
including some multi-dose products, and in
general should be used in preference to
preservative containing preparations in any more
than mild disease or with instillation more than
three or four times daily.
If possible, preservative-free formulations should also
be used for dry eye patients when other topical
medication is required, for example in the treatment
of glaucoma.
Newer preservatives such as Polyquad and Purite
seem to exhibit lower ocular surface toxicity than
older agents such as benzalkonium chloride. 26
Other eye drop solutions:
￮ Some other solutions have been used to
replace tears, one mainly known is
autologous serum are usually used during
mucin deficiency (acts as mucomimmetic).
The use of blood and its components as a
pharmaceutical preparation in many countries
is restricted by specific national laws.
To produce serum eye drops and to use them
for outpatients, a license by an appropriate
national body may be required in certain
countries.

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3
Therapy
Strategy
DEWS Guidelines (from Kanski’s Clinical
Ophthalmology)

￮ The underlying causative processes of dry eye

are generally not reversible and management
is therefore structured around the control of
symptoms and the prevention of surface
damage.
DEWS have produced guidelines based on earlier
International Taskforce Guidelines for Dry Eye, in
which suggested treatment options depend on the
level of severity of disease graded from 1 to 4.
The DEWS guidelines can also be applied in a
graded approach, proceeding to the next level if
the preceding measures are inadequate.

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Moshirfar et al.
￮ A systematic literature review done by
Moshirfar et al. (2014) analyzed 18
head-to-head clinical studies on
artificial tears. Moshirfar et al. came up
with a schematic algorithm for the
treatment of Dry Eye using artificial
tears

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References:

1. VAUGHAN, D., & ASBURY, T. (2018). Vaughan & Asbury's

general ophthalmology. New York, Lange Medical
Books/McGraw-Hill.
2. Larson T. Artificial Tears: A Primer. EyeRounds.org. November
23, 2016; Available from http://
EyeRounds.org/tutorials/artificial-tears.html
3. KANSKI, J. J. (2016). Clinical ophthalmology: a systematic
approach. Edinburgh, Butterworth-Heinemann/Elsevier.
4. Moshirfar, et al. (2014). Artificial tears potpourri: A literature
review. Dovepress: Clinical Ophthalmology.
5. Foulks, et al. (2007). The 2007 Report of the International Dry
Eye WorkShop (DEWS). The Ocular Surface Vol. 5 No. 2.
6. Baoudouin et al. (2013). Role of Hyperosmolarity in the
Pathogenesis and Management of Dry Eye Disease:
Proceedings of the OCEAN Group Meeting. The Ocular Surface
Vol. 11 No. 4.
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